AGREEMENT - COMMUNITIES PUTTING PREVENTION TO WORK"' T �.. . � . •
AGRE�MENT BETWEEN �
TH� PINELLAS COUNTY HEALTH DEPARTMENT
205 Dr. M.L. King Street N., St. Petersburg, FL 33701
AND
CITY OF CI.EARWATER
112 S. Osceola Ave.
Clearwater, FL 33756
Preface
Attachment I
The State af Florida Purchase Order, being a legal and binding agreement, is sufficient to
procure goods and/or services. This agreement has been created as an attachment to
Purchase Order Number A'i4 1� The terms and conditions of this agreement shall become
part of the purchase order upan execution July 1, 2091 or when the agreement is signed by
both parties, whichever is later, until termination September 29, 2012. The criteria must be met
by campletion of this contract end date.
A. Services to be Provided
Definition of Terms.
a. Agreement Terms.
1) Department. The Pinellas County Health Department (PinCH�� is
a state and county funded health departmerit of the Florida
Department of Health (DOH) with jurisdiction over Pinellas
County.
2) Provider. The City of Clearvvater, Florida, created by Chapter
9710, Special Laws of Florida, 1923, as amended, exists as a
municipal corporation with all governmental, corporate and
proprietary powers to enable it to conduct municipal government,
perForm municipal functions and render municipal services.
3) Communities Putting Prevention to Work (CPPV1� - A�'ed�ral
award funded by the Prevention and Public Health Fund included
in the Affordable Care Act, the program will provide a
comprehensive prevention and wellness initiative administered by
the Centers for Disease Contral and Prevention (CDC).
b. Program 5pecific Terms.
Community Action Plan (CAP) — Worlt plan which describes an overall
integrated strategy that identifies the selected interventions; describes
key activities; describes milestones and timelines on achi�ving
intervention implementation; identifies anticipated policy outcomes.
2. General Description.
a. General Statement. Through implementing evidence and practice
based approaches in policy, systems, and environmental change,
CDC's Communities Putting Prevention ta Wark program aims to
achieve braad reaching, highly impactFul, and sustainable change ta
reduce chronic disease morbidity and martality associated with obesity
and tabacco use.
b. Authority. Grant Title: Communities Putting Prevention to Work, CFDA
#83.520. Caoperative Agreement 1 U58DP00252�-Q1.
PinCHD OS/24/11
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Attachment I
c. Scope of Service. ServicQS provided seek to reduce the burden of
abesity by focusing an healthier food access and choices and
increasing physical activity. This agreement will provide services
through Pinellas County targeting underserved populations.
d. Major Program Goals. Major goals of the program are to achieve broad
reaching, highly impactful, and sustainable change to reduce chranic
disease marbidity and mortality assaciated with obesity implementing
evidence and practice-based approaches in policy, systems, and
environmental change. Purpos� for this contract is to obtain data
collection, policy analysis and implementation for Cooperative
Agreemerrt requirements.
8. Manner of Service Provisian
Service Tasks.
a. Tasks List.
1) Continue to house and provide supervision f�r one full time
Wellness Specialist dedicated to CPPW project. Wellness
Specialist will serve on the CPPW Membership Team.
2) Conduct assessments/surveys of:
i. Wellness palicies/programs for employees.
ii. Public event. policies/programs.
iii. Bicycle and pedestrian infrastructure minor renovation
needs.
iv. Lighting and signage requirements for bike and pedestrian
usage in key locations.
v. �ther surveys as requested by CPPW evaluation team.
3) Promote city-wide healthy lifestyle awareness campaigns at public
events within the City of Clearwater.
4) Develop/implement policies that focus on healthy lifestyles in the
workplace to include consumption of fresh tap water, increased
physical activity, healthy foad choices and safe, clean areas far
lactating mothers.
5) Developrmplement policies ta pramote healthy choices at
community events.
6) Prepare evaluation surveys, reports/summaries pe� pragram and
CDC requirements.
7) Attend monthly membership team meetings.
$) Attend/present program information at City Council.meetings.
9) Dev�lop/Implement Bicycle Sharing Pilot Program.
10) Implement minor renovations to parks/trails to promote safe
access for physical activity.
11) Collaborate with all CPPW partners including evaluatian and
media services.
b. Perfarmance Measure.
1) Staff retained for duration of agreement.
2) 1pQ% all required assessments completed.
3) 2 campleted City wide awareness campaigns/year.
4) Palicies develaped and implemented for worksite and cammunity.
5) 100% surveys, reports/summaries completed as required.
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Attachment I
6) Bicycle pragram in plac� by August 2Al2.
7) At least 80% attendance at required meetings.
2. Deliverables.
a. Service Units. Provider will fund 1 FTE for wellness palicy
analysis/implementation.
b. Reports. Provider will submit quarterly reports and a final project report
to the Program Manager on the implementation and evaluation of
interventions contained within the CAP and anticipated policy autcomes.
- 3. Provider Responsibilities.
a. Provider Unique Activities:
1) The provider agrees to comply with agreement specifications
listed in B.2.a. and B.2.b.
2) The provider agrees to comply with General Agreement Terms
and Conditions, (Attachment IA).
b. Coordination with Other Providers/Entities. The provider agrees to
coordinate with the collaborating CPPW partners. Failure of other
providers ar entities does not alleviate the provider from any
accountability far tasks or services that the provider is obligated #o
perform pursuant to the agreement.
4. Department Responsibilities.
a. Department Obliga#ions:
1) CPPW Pragram Manager will provide project management and
coordination of program components.
2) CPPW Program Manager will liaise with partnering staff.
3) CPPW Program Manager will track pertormance outcomes, quality
improvement, and evaluation activities.
b. Department D�t�rminations. The department has final autharity over
approving the quality and acceptability of service deliverables.
C. Methad of Payment
1. Payment.
This is a cost-reimbursement agreement. The department shall reimburse the
provider for allowable expenditures incurred pursuant to the terms of the
agreement fior a total dollar amount not ta exceed $99,700.00 subject to the
av�ilability of funds.
2. Invoice Requirement.
a. The provider shall request reimbursement on a manthly basis through
submission af a properly completed invoice (Attachment II) within 15
days following the end of the period for which reimbursement is being
requested. Charges on the invoice must be accampanied by supporting
documentation for expenses and a summary of the information
demonstrating the completian af each sp�cific deliverable.
b. Any portion of the deliverable payments received that are not supparted
by documentation will be returned to the department. Deliverables that
3 PinCHD OS/24/X 1
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Attachment I
have been received or have been received and not determined to be
acceptable will not be paid or considered for cost reimbursement.
c. Payments may be authorized only for allowable expenditures on the
invoice which are in accordance with the limits specified on the
approved line item budget (Attachment III).
d. All information technology procurements must be approved in writing
prior to purchase by the DepartmenYs Information Technology Director.
The Department af Health Information Technology Acquisition Policy
DOHP 50-9-04 provides further clari�cation on the appraval process.
Technology items purchased withaut prior approval may not be
authorized for reimbursement.
e. The provider can only exceed the individual line item budgets within
20°/a of the total budget of the respective line item for the agreement
period. Any expenditurE of mor� than 20% af en individual line item
budget must have priar written request and just�cation from the
provider and approval by the Pragram Director.
3. Expenses.
a. Receipts are required for all expenses incurred, (e.g., client '
incentives/aperatina supplies, etc.) that are authorized under this
agreement.
b. Travel: For all travel expenses, authorized under this agreement, a
travel voucher, Farm C-67G (State of Florida Voucher for
Reimbursement of Traveling �xpenses) must be submitted. Original
receipts for expenses incurred during officially authorized travel (items
such as car rental and air transportation, parking and lodging, tolls and
fares) are rer�uired for reimbursement. 5ection 2$7.q5$ (1)(b), Florida
Statutes, requires that bills for any travel expense shall be submitted in
accordance with section 112.061, Florida Statutes, governing payments
by the state for traveling expenses. Department of Health 40-1 (Official
Travel of Department of Health Employees and Nan-Employees)
provides further explanatian, clar�cation and instruction regarding the
reimbursement of traveling expenses necessarily incurred during the
perFarmance of official state business.
D. Special Rrovisions
1. Federal Funds Clause.
The approximate amaunt of federal funds contained in the total contract amaunt
is $_88,�7Q0.00. The Catalague of Federal Domestic Assistance (CFDA) Number
is #93.520.
2. The provider agrees to utilize the U.S. Department of Homeland Security's E-
Verify system, htttas://e-verify.uscis.aov/emq to verify the employment eligibility
of: (a) all persans employed during the contract term by the contractor to pertorm
employment duties within Florida; and (b.) all persons (including subcontractors)
assigned by the cantractor to pertorm work pursuant ta the cantract with the state
agency. Contractors meeting the terms and conditions of E-verify are deemed to
be in compliance with this provision.
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E. Attachments
1. Attachment IA - Gener�l Agreement Terms and Conditions
2. Attachment IB - Financial and Compliance Audit
3. Attachment II — Contract Invoice
4. Attachment III — Line Item Budget
PINELLAS COUNTY HEALTH
D�PARTMENT
By:
Claude Dharamraj, M.D., M. .H., F.A. ..
Director
�
Attachment I
CITY OF RWATER, FLORIDA
evin Dunbar ,
Parks and Recreation Director
City of Clearwater
M.�t�*irliF�frZlfil
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GENERAL AGREEMENT TERMS AND CONDITIONS
A. Monitoring
Attachrnent IA
1. Records and Dacumentation.
The provider agrees to maintain fiscal records documEnting all
expenditures that are applicable to this cantract, participant records, and
curriculum materials used in the provision of services. Records will be
available for review by the department.
2. Monitoring and Evaluation Methodalogy.
By execution of this agreement the provide� hereby acknowledges and
agrees that its pertormance under the agreement must meet the standards
s�t forth above and will be bound by the conditions set forth below. lf the
provider fails to meet these standards, the department, at its extlusive
option, may allow up to three (3) manths (or ather specified time frame
depending on the agreement duration) for the provider ta achieve
compliance with the standards. If the department a#fords the provider an
opportunity to achieve compliance and the provider fails to achieve
compliance within the speci�ed time frame, the department will terminate
the agreement in the absence of any extenuating or mitigating
circumstances. The determination af the extenuating or mitigating
circumstances is the exclusive det�rmination of the department.
B. Termination
1. Termination at Will.
This agreement may be terminated by either party upan no less than thirky
(3p) calendar days noticc in writing to the other party, withaut cause, unless
a lesser time is mutually agreed upon in writing by both parties. Said notice
shall be delivered by certified mail, retum receipt requested, or in person
with proof af delivery.
2. Termination Because of Lack of Funds.
In the event funds to finance this agreement become unavailable, the
department may terminate the agreement upan no less than twenty-faur
(24) hours notice in writing to the provider. Said notice shall be delivered by
certified mail, retum receipt requested, or in person with proof of delivery.
The department shall be the final autharity as to the availability and
adequacy of funds. In the event of termination of this agreement, the
provider will be compEnsated for any work satisfactorily completed prior to
natification of termination.
3. Termination for Breach.
This agreement may be terminated for the provider's non-perFormance
upon na less than twenty-four (24) hours notice in writing to the provider. If
applicable, the department may emplay the default pcovisions in Chapter
FOA-1.006 (3), FAC. Waiver of breach af any provisions of this agreement
shall not be deemed to be a waiver of any other breach and shall not be
construed ta be a modificatian of the terms of this agreement. The
provisions herein do not limit the department's right to remedies at law or in
equity.
4. Termination for Failure to Satisfactorily Pertorm Prior Agreement.
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Attachment IA
Failure to have performed any contractual obligations with the department
in a manner satisfactory to the department will be sufficient cause for
termination. To be terminated as a provider under this provision, the
provider must have: (1) previnusly failed to satisfactorily perForm in an
agreement with the department, been notified by the. department of the
unsatisfactory pertormance, and failed to correct the unsatisfactory
pertormance to the satisfaction of the department; or (2) had an agreement
terminated by the department for cause.
C. No L.obbying
State funds cannot be used to lobby the �xecutive or Legislative branches of the
Federal Government in connectian with the department.
D. Discriminatory Vendor List
Provider acknowledges it is infarmed of the provisions of 287.134 (2)(a), F.S., and
represents to the department that thnse provisians do not prohibit the department
from contracting with the provider or �ny subcontractors h�reunder.
E, Background Check
The provider must comply with the palicy af the Department of Health, which requires
employees and certain other persons in pasitions of special trust, responsibility, or
sensitive location to be background screened in accordance with Sections 110.1127
and 435.04, Florida Statutes. Initial screening includes fngerprint checks through the
Florida Department of Law (FDLE) and the Federal Bureau of Investigation (FBI).
Re-screening requires only correspandence checks through FDLE every five (5)
years.
�'. Inform�tion Security
The provider shall maintain confidentiality of all data, files, and records including
client records related to the services provided pursuant to this agreement and shall
comply with state and federai laws, including, but not limited ta, sections 384.29,
381.QD4, 392.65, and �58.057, Florida Statues. Procedures must be implemen#ed by
the provider to ensure the protectian and confidentiality of all confid�ntial matters.
These procedures shall be consistent with the Department of Health Infarmatian
Security Palicies capyright 20D7, as amended, which is incorporated herein by
r�ference and the receipt of which is acknawledged by the Provider, upon execution
of this agreement. The provider will adhere to any amendments to the department's
security requirements pravided to it during the period of this agreement. The provider
must also comply with any applicable professional standards of practice with respect
to the client confidentiality. There must be an individual designated with specified
responsibility for managing the security and confidentiality of this data. It is the
responsibility of the contract p�ovider designee to develop policies, which ensure the
confidential flow of client information between autho�ized staff and the provider.
Discipline will be applied for breach of security of confidential information cansistent
with Florida Statues, Flarida Administrative Code, and Department of Health
protocols, policies and procedures. The con#ract manager performs information
security assessments of contract pro�iders during scheduled compliance visits.
PinCHD 01/25/11
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Attachment IA
G. HIPAA
Where applicable, the provider will comply with� the Health Insurance Portability and
Accauntability Act as well as all regulations promulgated there under (�45CFR Parts
16q, 1 fi2, and 1 B4).
H. Public Access
Allow public access to all documents, papers, letters, or other materials subject to
the provisions of Chapter 119, FS, made ar received by the provider in conjunction
with this contract. It is expressly unde�tood tliat the provider's refusal ta comply with
this provision shall constitute an immediate breach of contract.
I. Construction or Renovation of �acilities Using State Funds
Any state funds provided for the purchase of or improvements to real property are
contingent upon the provider granting ta the state a security interest in the property
at ieast to the amaunt of the state funds pravided for at least fiv� (5) years from the
date of purchase or the completion of the improvements or as further required by
law. As a condition of a rec�ipt of state funding for this purpase, the provider agrees
that, if it disposes af the praperty before the department's interest is vacated, the
provider will refund the prapartionate share of the state's initial investment, as
adjusted by depreciation.
J. Insurance
Ta provide adequate liability insurance coverage on a comprehensive basis and to
hold such liability insurance at all times during the existence af this contract and any
renewal(s) and extensian(s) of it. Upon execution of this contract, unless it is a state
agency or subdivision as defined by §768.28, FS, the pravider accepts full
responsibility for identifying and determining the type(s) and extent af liability
insurance necessary ta provide reasonable financial protectians for the provider and
the clients to be served under this contract. Upon the execution of this contract, the
pravider shall furnish the department written verification supporting bath the
determination and existence of such insurance coverage. Such coverage may be
provided by a self-insurance program established and operating under the laws of
the State of Florida. The department reserves the right to require additional
insurance. �
K. Indemnification
The provider shall be liable for and shall indemnify, defend, and hold harmless
the department and all of its officers, agents, and employees from all claims,
suits, judgments, ar damages, consequential or othervvise and including
attameys' fees and costs, arising out of any act, actions, neglect, or omissians by
the provider, its agents, or employees during the performance or operation of this
contract or any subsequent modifications thereof, whether direct or indirect, and
whether to any person or tangible or intangible property.
8 PinCWD 01/25/11
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Attachment IA
2. The provider's inability to evaluate liability or its evaluation of liability shall not
excuse the provider's duty to defend and indemnify within seven (7) days after
such notice by the department is given by certified mail. Only adjudication or
judgment after highest appeal is exhausted specifically finding the provider nat
liable sh�ll excuse performance of this provision. The pravider shall pay all costs
and fees related to this obligation and its enfarcement by the department. The
department's failure to notify the provider of a claim shall nat release the provider
af the abave duty to defend.
END OF TEXT
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03/11 Attachment IB
ATTACHMENT
FINANCIAL AND COMPLIANCE AUDIT
The administratian of resources awarded by the pepartment of Health to the provider may be subject to audits and/or
monitoring by the Dapartment of Health, as described in this section.
MONITORING
In addition to reviews of audits conducted in accardance with OMH Circular A-133, as revised, and Section 215.97, F.S.,
(see "AUDITS" below), monitoring procedures may include, but not be limited to, on-site visits by DepaRment of Mealth
staff, limited scope audits as defined by OMB Circular A-133, as revised, and/or other procedures. By entering into this
agreement, the provider agrees to comply and cooperate with any monitoring procedures/processes deemed appropriate
by the bepartment of Health. In the event the Department of Health determines that a limited scope audit of the provider is
appropriate, the provider agrees to comply with any additional instructions provided by the Department of Health ta the
provider regarding such audit. The provider further agrees to comply and cooperate with any inspections, reviews,
investigations, or audits deemed necessary by the Chief Financial Officer (CFO) or Auditor General.
AUDITS
PART !: FEDERALLY FUNDED
This part is applicable if the provider is a State or local govemment vr a non-profit organization as defined in QMB Circular
A-133, as revised.
In the event that the provider expends $500,000 or more in Federal awards during its flscal year, the provider must
have a single or program-specific audit canducted in accordance with the provisians of OMB Circular A-133, as
revised. EXHIBIT 1 to this agreement indicates Federal resources awarded through the []epartment of Health by
this ag�eement. In determining the Federal awards expended in its fiscal year, the provider shall consider all
sources of Federal awards, including Fadera! resources r�ecelved from the Department of Health. The
determinatian of amounts of Federal awards expended should be in accardance with the guidelines established by
OMB Circular A-133, as revised. An audit of the provider conducted by the Auditor General in accordance with the
provisions of OMB Circular A-133, as revised, will meet the requiremants of this part.
In connection with the audit requirements addressed in Part I, paragraph 1, the provider shall fulfill the
requirements relative to auditee responsibilities as provided in Subpart C of OMB Circular A-133, as revised.
If the provider expends less than $500,000 in Federal awards in its fiscal year, an audit conducted in accordance
with the provisions of OMB Circular A-133, as revised, is not requlred. In the event that the provider expends less
than $500,0�0 in Federal awards in its flscal year and elects to have an audit conducted in accordance with th�
provisions of OMB Circufar A-133, as revised, the cost of the audit must be paid from non-Federal resources (i.e.,
the cost of such audit must be paid from provider resources obtained from other than Federal entities.)
4. An audit conducted in accordance with this part shall cover the entire organization for the organization's fiscal
year. Compliance findings related to agreements with the Department of Health shall be b�sed on the
agreemenYs requirements, including any rules, regulatians, or statutes referenced in the agreement. The financial
stataments shall disclase whether or not the matching requirement was met for each applicable agreement. Alt
questioned casts and liabilities due to the pepartmerrt of Nealth shall be fully disclosed in the audit report with
reference to the pepartment of Health agreement involved. If not othervvise disclosed as required by Section
.310(b)(2) of OMB Gircular A-133, as revised, the schedule of expenditures af Federal awards shall identify
expenditures by agreement number for each agreement with the Deparkment of Health in effect during the audit
period. Financial reporting packages required under this part must be submitted within the eaMier of 30 days after
receipt of the audit report or 9 months after the end of the provider's flscal year end.
PART II: S7A7E �UNDED
This part is applicable if the provider is a nonstate entity as defined by Section 215.97(2}, Florida Statutes.
ro
03/11
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Attachment IB
In � the event that the provider expends a total amount of state financial assistance equal to or in excess of
$500,000 in any fiscal year of such provider (for fiscal years ending September 30, 2004 or thereafter), the
provider must have a State single or project-specific audit for such fiscal y�ar in accordance with Section 215.97,
Florida Statutes; applicable rules of the Department of Financial Services; and Chapters 10.550 (local
govemmental entities) �r 1 p.B5D (nonprofit and for-profit organizations), Rules of the Auditor General. EXHIBIT I
to this agreement indicates state financial assistanca awarded through the Department of Health by this
agreement. In determining the state financial assistance expended in its fiscal year, the provider shall consider �II
sources of state finanaal assistance, including state financial assistance received from the Department of Health,
other state agencies, and other nonstate entities. State financial assistance does not include Federal direct or
pass-through awards and resources received by a nonstate entity for Federal program matchfng requirements.
2. In connection with the audit requirements addressed in Part II, paragraph 1, the provider shall ensure that the audit
complies with the requirements of Section 215.97(8), Florida Statutes. This includes submission of a financial
reporting package as defined by Section 215.97(2), Florida Statutes, and Chapter 10.550 (local govemmental
entities) a�r 10.650 (nonprofit and for-proflt organizations), Rules of the Auditor General.
3. If the provider expends less than $500,000 in state financial assistance in its �iscal year (for fiscal years ending
September 30, 20�4 or thereafter), an audit conducted in accordance with the provisions af Section 215.97,
Florida Statutes, is not required. In the event that the provider expends less than $500,U00 in state financial
assistance in its fiscal year and elects to have an audit conducted in accordance with the provisions of Section
215.97, Florida Statutes, the cost of the audit must be paid from the nonstate entiry's resources (i.e., the cost of
such an audit must be paid from the provider resources obtafned from other than 5tate entities).
4. An audit conducted in accordance with this part shall cover the entire organization for the organization's fiscal
year. Compliance findings related to agreements with the Department of Health shall be based on the
agr�ment's requirements, including any applicable rules, regulations, or statutes. The financial statements shall
disclase whether vr not the matching requiremerrt was met for each applicable agreement. All questioned costs
and liabilities due to the Dapartment of liealth shall be fully disclosed In the audit report with reference to the
Department of Health agreement involved. If not othervvise disclosed as required by Rule 691-5.003, Fla. Admin.
Code, the schedule of expenditures of state financial assistance shall identify expenditures by agreement number
for each agreement with the Department af Health in effect during the audit period. Financial reporting packages
required under this part must be submitted within 45 days after delivery of the audit report, but no later than 12
months after the providers fiscal year Qnd for lacal govammantal entities. Non-profit or for-profit organizations are
required to be submitted within 45 days after delivery of the audit report, but no later than 9 months after the
provider's fiscal year end. Notwithstanding the applicability of this portion, the Department of Health retains all
right and obligatfon to monitor and oversee the performance of this agreement as outlined thraughout this
document and pursuant to law.
PART 111: REPORT SUBMISSION
Copies of repoRing packages for audits conducted in accordance with OMB Circular A-133, as revised, and
required by PART I of this agreement shall be submitte�d, when required by Section .320 (d), OMB Circular A-133,
as revised, by or on behalf af the provider directiv to each of the following;
11
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[�k)fifi
Attachment IB
A, The Department of Health as fallows:
Sin�leAudits(c3�doh.state.fl.us
Audits must be submitted in accordance with the instructions set forth in Exhibit 3 hereto, and
accompanied by the "Single Audit Data Collection Form." Files which exceed 8 MB may be
submitted on a CD ar ather electronic storage medium and mailed to: Contract Administrative
Monitoring Unit, Attentfon: Single Audit Review, 4052 Bald Cypress Way, Bin 601 (I-IAFACM),
Tallahassee, FL 32399-1729.
B. The Federal Audit Clearinghouse designated in OMB Circular A-133, as revised (the number of copies
required by Sections .320 (d)(1) and (2), OMB Circular A-133, as ravised, should be submitted to the Federal
Audit Clearinghouse), at the following address: �
Federal Audit Clearinghouse
Bureau of the Census
1201 East 10`� Street
Jeffersonville, IN 47132
C. Other Federal agencies and pass-through entities in accordance with Sectlons .32� (e) and (�, OMB Circular
A-133, as revised.
Pursuant to Sections .320(fl, OMB Circular A-133, as revised, the provider shall submit a copy of the reporting
package described jn Section .320(c), OMB Circular A-133, as revised, and any management letter issued by the
auditor, to the Department of Health as follows:
Sin IeAudits doh.state.fl.us
Audits must be submitted in accordance with the instructions set forth in Exhibit 3 hereto, and
accompanied by the "Single Audit Data Collection Form." Files which exceed 8 MB may be
submitted on a CD or ather electronic storage medium and mailed to: Contract Administrative
Monitoring Unft, Attention: 5ingle Audit Review, �4052 Bald Cypress Way, Bin B01 (HAFACM),
Tallahassee, FL 32399-1729.
3. Additionally, copies of financial reporting packages required by Part II of this agreement shall be submitted by or
on behalf of the provider di_ recUY to each af the fWlowing:
A. The Departmant of Health as follows:
SingleAudits(dldoh,5iate.fl,us
Audits must be submitted in accordance with the instructions set forth in Exhibit 3 hereto, and
accompanied by the 'Single Audit Data Collection Form." Files which exceed S M8 may be
submitted on a CD or other electronic storage medium and mailed to: Contract Administrative
Monit�ring llnit, Attention: Single Audit Review, 4052 Bald Cypress Way, Bin B01 (HAFACM),
Tallahassee, FL 32399-1729.
B. The Auditor General's Office at the following address:
Auditar GeneraPs OfFce
Claude Pepper �uilding, Room 401
111 West NAadison Street
Tallahassee, Florida 32398-1450
i`a
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Q3/11
Attachment I�
�F. Any reports, management letter, or other information requlred to be submitted to the Department of Health
pursuant to this agreement shall be submitted timely in accordance with OMB Circular A-138, Florida Statutes, and
Chapters 1 Q.55� (local govemmental entities) or 10.650 (nonprofit and for-prafit organizatiarrs), Rules of the
Auditar General, as applicable.
5. Providers, when submitting financial reporting packages to the Department of Health for audits done in accordance
with OMB Circular A-133 or Chapters 10.550 (local govemmental entities) or 1 p.65Q (nonprofit and for-proft
organizations), Rules of the Auditor General, should indicate the date that the reporting package was delivered to
the provider in correspondence accompanying the reporting package.
PARi IV: RECORD RETENTION
The provider shall retain sufficient records demonstrating its campliance with the terms of this agreement for a period of six
years from the date the audit report is issued, and shall allow the pepartment of Health or its designee, the CFO ar Auditor
General access to such records upon request. The provider shall ensure that audit wvrking papers are made available to
the DepaRment of Health, or Its designee, CFO, or Auditor General upon request for a period of six years from the date the
audit repart is issued, unless extended in writing by the DepaRment of Health.
End of Text
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03/11
EXHIBIT -1
Attachment IB
1. FEDERAL RE$OURCES AWARDED TQ TH� SUBRECIPIEN7' PURSUANT TO THIS AGREEMENT CONSISI' OF 7ME
FOLLOWING:
Federal Program 1 Coo�erative Aareement GFDA# 93.520 TiUe C�FMf $ 99,700.00
Federal Program 2 GFpA# Title $
TOTAL FEDERAL AWARDS �89,700.00
COMPLIANCE REQUIREMENTS APPLICABLE TO TWE FE�ERAL RESOURCES AWARDHD PUFiSUANT T� 7HI3 AGREEMENT
ARE A5 FOLLOW$:
2. STATE RESOURGES AWARDED T� THE RECIPIENT PURSUAN'I' TO THIS AQREEMENT CaNSIST OF TH�
FOLLOWIN(i:
Matching resources for federal program(s) CFDA� Title $
State financial assi�tance subject to Sec. 215.97, F'.S.: CSFA# Title $
TOTAL $TATE FINANCIAL ASSISTANCE AWARDED PURSUANT TO 5EC'fION 215.97, F.S. $�oommo0.......o.
CQMPLIANCE REQIlIR�M�NTS APPI.IGABLE TO STA7E RESOURCES AWARDED PURSUANT TO THIS AGR�EMENT ARE AS
FOLLOWS:
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03/11 Attachment IB
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PART I: AU�IT RELATIONSHIP DBTERMINATION
Providers who receive state or federal resources may or may not be subjed to the audit requirements of OMB Circuler A-133, as revised,
and/or 5ectipn 215.97, Fla. Stat. Providers who are determined to be reapients or subreapients of foderal awards andlor state financial
assistance may b� subject to the audit requiraments if the audit threshold requiremeMs set foRh in Part I andlor Part II of �xhibit 1 are
met. Providers wha have beer� determined to be vendors are not subject to the audit requirements of OMB Circular A-133, as revised,
andlor Section 215.97, Fla. Stat. Regardless of whether the audit requirem�nts are met, providers who have be�n determined to be
recipients or subrecipients of Federdl awarcJs and/ar state finandal assistance, must comply with applicable programmatio and fiscal
compliance requirements.
In accordance with Sec. 210 of OMB Clrcular A-133 and/or Rule 699-6.006, FAC, provider has been determined to be:
X Vendor not subject to OMB Circular A-133 and/or Section 215.97, F.S.
Recipientlaubrecipient subject to OMB Cireular A-133 and/ar Section 215.9'7, F.S.
Exempt organization not subject to OMB Circular A-133 and/or Section 215.97, P.S. For Federal awards, for-profit
organizations are exempt; for state financial assistance projeds, public univarsities, community colleges, district school boards,
branches of state (Florida) govemment, and charter schools are exempt. Exempt organizations must comply with all cornpliance
requirements set forth within the cantract or award document.
NOTE: If a provider is determined to be a recipiendsubrecipient of federal and or state financial assistance and has been approved by
the department to.subcontract, they must comply with Section 215.97(7), F.S., and Rule 69I-.006(2), FAC [state financial assistancej
and $ection _.400 OMB Circul�r A-133 [federal awards].
PART II: FISCAL CpMPL1ANCE REQUIREMENTS
FEDERAL AWARpS OR STATE MATCHING FUNDS �N FEDERAL AWARDS. Providers who receive Federal awards, state
maintenance of effort funds, or state matching Funds on Federal awards and who are determined to be a subrecipient, must comply with
the following fiscal laws, rules and regulations:
STATES, LOCAI. GOVERNMENTS AND INDIAN TRIBES MUST FOLLOW:
2 CFR 225 a/k!a OMB Gircular A-87 — Cost Prinaples"
�MB CircularA-102—Adminiatrativa Requirements*"
OMB Circular A-133 — Audit Requirements
Refe�ence Guide for State Expenditures
Other fiscal requirements set farth fn program laws, rules and regulations
NON-PR�FIT ORGANIZATIONS MUST FOLLOW:
2 CFR 230 a/k/a OMB Circuler A-122 — Cost Prinaples•
2 CFR 215 a/k/a �MB CircularA-110—Administrative Requirements
QMB Circular A-133 — Audit Requirements
Reference Guide for 5tate Expenditurea
Other fiscal requirements set fo�th in program laws, rules and regulations
EDUCATIONAL INSTITUTIONS (�V�N IF A PART OF A S7ATE OR LOCAL GOVERNMENT) MUS1' FOLLOW:
2 CFR 220 a/k/a OMB Cirr.ular A-21 — Cost Principlas'
2 GFR 215 a/k/a OMB Circular A-110 — Administrative Requirements
�M8 Circular A-133 — Audit Requirements •-
Reference Guide for State Expenditures
Other fiscal requh'ements set forth in prqgram laws, rules and regulations
"Some Federal programs may be exempted from compliance with the Cost Prinaples Circulars as nated in the OMB Circular A-
138 Compiiance Supplement, Appendix 1.
"For funding passed through U.S. Health and Human Servic:es, 45 CFR 92; for funding passed through U.S. Department of
Educatlon, 34 CFR 80.
STATE FINANCIAL AS5ISTANCE. Providers who receive state financial assistance and who are determined to be a
redpienUsubrecipient, must comply with the following fiscal laws, rules and regulations:
Section 215.97, Fla. Stat.
Chapter 691-5, Fla. Admin. Gode
State Projects Complianc� Supplemant
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03/11
Refersnce Guide far State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
Attachment IB
Additional audit guidance or copies of the referenced fiscal laws, rules �nd regulations may be obtained at 1Ltk�:/lv�r,doh.state.fl.us/ by
s�lecting 'Cpntract Administrative Monitoring' in the drop-down bax at the top of the Departrnent's webpage. ` Enumeration of laws, rules
and regulations harein is not exhaustiv� nor exdusive. Fund recipieMs will be held to applicable (egal requirementa whether or not
outlined herein.
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03/11
�XHIBIT 3
INSTRUGTIQNS FOR ELECTRONIG 8UBMISSION
OF SINC,LE•AUDIT REPORTS
•
Attachment IB
�ffective April 1, 2011, Single Audit reporting padcages ("SARP°) must be submltted to the qepartment in an electronic format. This
change will eliminate the need to submlt multiple copies af the reparting padcage to the Contract Managers and varioua sections within
the Department and will �sult in efficiencies and cost savings fa the Provider and the pepartment. Upon receipt, the SARP's will be
posted to a secure server and aocessible to Departmentstaff.
The electronic copy of the SARP should:
9 Be in a Portable qocument Format (PDF).
➢ Indude tha appropriate letterhead and signatures in the reports and management letters.
➢ Be a single••document. However, if the financial audit is issued seperately from the Single Audit reports, the financial audit
reporting packege may be submitted as a single document and the 5ingle Audit reports may be submitted as a'single document.
Documents which excaed 8 megabytes (MB) may be stored on a CD and mallad to: Contract Administrative Monitoring Unit,
Attention: 5ingle Audit Review, 4052 Bald Cypress Way, Bin B01 (HAFACM), Tallahassee, FL 32389-1729.
➢ Be an exact copy of the final, signed SARP provided by the Independent Audit firm.
A Not have secu�ity settings applied to the electronic fle.
D Be named using the following convention: [flscal yearJ [name of the auditad entity exactly as atat�d within the audit report].pdf.
For example, if the SARP is for the 2009-10 fiscal year for the Clty of Gainesville, the document should be entitled 2010 City of
Gainesville.pdf.
➢ Be accompanied qy the attached "5'ingle Audit bata Collection Form.° This dxument is necessary to ensure that
communications related to SARP issues are directed to the appropriate individual(s) and that compliance with Single Audit
requirements is properiy captured.
Questions regarding electronic submissians may be submitted via e-mail to Sin9leAuditS_(d1dOh.Stet@.fl.us or by telephone to the
5ingle Audit Review Section at (850) 245-4444 ext. 3071.
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Attachment IB
Single Audit Data Collection Form
GENERAI. INFORMATION
1. Flscal perivd ending date for the Single Audit. 2, AudiLee Identification Number
a. Primary Employer ldentiflcation Number (EIN)
Month Day Year
/ / � --
b. Are muRiple EINs covered in this report �Yes � No
c.. If "yes", complete No. 3.
3. ADDITIONAL ENTITIES COVERED IN THIS REP�RT
Employer ldentiflcation # Nam� Of Entity
4. AUDITEE INFORMATON 5. PRIMARY AUpIiOR INFORMAiION
a. Auditee name: a. Prlma auditar name:
b. Audltee address (number and street b. Primary audRor address (numbe� and street)
C Clty
State ilp Code State 1ip Code
c. Audltee tontatt c. Prlmary audltor wntad
Name: Name:
Title: 7itle:.
d. AudRee contact telephone d. Primary audltor tonWtt telephone
i 1 - c 1 -
e. Audlcee contaa FAX e. Prlmary auditor E-mall
I 1 - f 1 -
f. Auditee contaCt H-mail f. Auflit Flrm LICEn52 NUrtIbE�
& AuDffEE CER7IFICA'nOM 5TATEMENt — This �S to certify that, to the best of my pUpl'f�E CHRTIFIG4TION Date ��
knowledge and Bellef, the auditee has: (1) engaged an audltor to perform an audit
In atwrdance with the provlsions of OMB Clrcular A-133 and/or Sectbn 215.97, Fla. Date Audit Received From Auditor: ��
Statutes, for the peMod descrlbed In Item 1; (2) the audkpr has completed such
audlt and presented a slgned audlt repart whlch states that the audR was conduded Name of Certifying Official:
in accordance wKh the aforementloned Circular and/or Statute; (3) the atrached
audlY Is a true and accurate copy of the flnal audft report Issued by the audRor for (Please p�int Glearly)
the perlod described in item i; and (4) the InFormation Included In thls data Tltle af Certifying Offitial:
collection form Is aaurete and complete. I declare the forEgoing is true and carrect. (Please print clearlyJ
5ignature of Certifying O�cial:
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Attachment ZI
PINEI�LAS COUNTY HEALTH DEPARTMENT
CONTRACT IIdVO10E
FE� �OR CONTRACTUAL SERVIC�S DATE
FROM: City of Clearwater
112 S. Osceola Ave.
Clearwater, FL 33i56
TO: Pinellas County Health Department
Richard Curtin
2Q5 Dr. M. L. K. Street North
St. Petersburg, Florida 33�p1
PO #:
SERVIC� PERIOD: FROM: T�:
EXP�NDITURE TYPE APPROVED CURRENT
BUDGET REQUEST
Project Title $99,700 $
$ss,�oo $
TOTAL
Total Amount:
Prepared by: _
Approvad by: ,
(Signature)
Title:
Date:
INVOICE MUST BE RECEIVED BY PinCHD AS A HARD COPY WITH ORIGINAL
SIGNATIlRE,
For PinCHD Use Only:
Invoice Fteceived Date
Service Reoeived Da�e
I & A roved Date
Ob'ect Code
ORG B¢38�52-
OCA
DO/Contrad #
I certify that the goads and services have been received and
are approved for paymerrt.
(Sgnature )
�le
19 PinCHD 07/30/10
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City of Glearwater, Florida
l.ine Ibam Budget
07/01 /2011-09/29-2012
City of Clearwater - Florida
Staffing: Wellness Specialist (salary & frin�e) 1 FTE
Total Personnel costs
Expenses:
Travel:
Rautine in-county for Wellness Spec�alist �.445/m
Out of County/5tate: project staff, to attend
CF'I'W Peer to Peer meeting in Atlanta, February 2012.
�
Cell phone ($35.00/manth)�15 manths
Printing
Educational Materials
Office supplies for daily duties induding pens, printing supplies, prirrting cartridge etc.
Equipment: BicyGe Program- Bicydes, radcs, helmets, etc.
Emplayee/Public Wellness Program - public water fountains, lactation area supplies, etc.
City Park and Trail Enhancements, signage, safety decals, etc.
i ota� txpenses
Total Personnel costs and Expenses
ao
Attachment III
65,448
85,448
1,200
1,027
$ 525
$ 3,500
$ 1,500
$ 'S�
$ 5,000
� s,aoo
$ 12,000
S 34;252
98,700
. rJxdgr A44163 Page 1 of 2
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Order No. A44163
Issued on Fri, 01 Jul, 2011
Created an Fri, 01 Jul, 2011 by Ariba Systam
Suppller.
Ciiy of Clearwater, Florida
100 S. Myrtle Ave�
Clearwater, FL 33756-5520
United States
Phone: U3727-582�F533
Fax: US727-562�535
Contact: Jay Ravins
Shlp To: Bill To:
Pinellas County Health �ept Pinellas County Nealth Dept
205 Dr M L King St. N 205 ML King St North
4th Floor Rm 418
St Petersburg, FL 33701 attn accounts payable
Unitad States 5t Petersburg, FL 33701
United States
DelYver To: Entity Description: Departm�nt of Health
Gabriela Zarorska Organlza�on Code: 84385225210
06ject Code: 640000-131760
Expansion QpUon: C2
Exemption Status: No
Exemptfon Reason7:
VerslonNumber: 1
Item Description Part Number Unit Qty Nead By Unit Prke Extended Amount
1 Blanket direct order to cover the cost of pne... month 12 None $8,667.UOOOOUSb $80,004.00OODUSD
Blanket direct orcler to cov�r th� cpst of one full time policy consultant to conduct assessments and surveys of wellness policies and programs
for employees as per the attached MOA and as authorized by Rich Curdn or designee.
Specifics of services to be provided are stated in the attached MQA. Vendor will invoice on a monthly basis as per the terms and conditions of
the attached MOA. Invoices will vary du� to c�st reimbursement method of payment.
�istributors?: N
Requester: Gabriela Zatorska
Ship To Gode: A02e6jzx.q
State Contract ID:
Buyer Code:
Descriptlon
Bianket Purchase Order
Itemized Invoice
PR No.: PR5722252
Requester Phone:
MasterAgreement Ip:
MyGreenFlorida Content: N
Method of Procurement:: L- gavemmental agency per 287.057(3)(�13, defined In 183.3184(10).
Shipping Method: Best Way
FOB Code: INC-Dest
FQ8 Cpde pescription: Destination freight paid by vendar and induded in price. Title passes upon receipt. Vendor files any Gaims.
Encumber Funds: Yes
PQ Start Date: Fri, 1 Jul, 2011
PO End Date: Sat, 30 Jun, 2012
https://myfloridamarketplace.com:9140Buyer/rend�r/12MRSLMEWS2GW 7/26/2011