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HomeMy WebLinkAboutRefugee Health Screening 10/11/12 Docu9ign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A "41`"1,6, Governor Scott Walker Wisconsin department of Secretary Eloise Anderson children & families 201 East Washington Avenue, Room A200 Division of Family and Economic Security P.Q. Box 8916 Madison, WI 53708-8916 [October 4, 2011] Dear Refugee Health Screening Provider: With funding from the U.S. Office of Refugee Resettlement(ORR), a branch of the Department of Health and Human Services/Administration for Children and Families,we would like to enter into a contract with your agency to provide newly arriving refugees with important health screening and health education services.The eligibility period for serving this group remains the first 90 days following their entry into the United States. Procedures for submitting claims and reports are as follows: Financial Reimbursement Claims and Reporting: The Expenditure Report must be submitted to the Department of Children and Families by close of business(4:3o pm CT) on or before the loth day of the month following the month for which reimbursement is being claimed. The Department will issue the reimbursement using direct deposit on the last business day of the same month,subject to reduction, recovery and reimbursement as provided in the attached Agreement. Late reports will be processed in the next month's payment cycle. If the loth day of the month and/or the 30th day of the month fall on a non-business day(per the State of Wisconsin calendar),the Expenditure Report due date and/or reimbursement date will be the next business day. The payment schedule is available on the CORe website: http://dwd.wisconsin.gov/CORe/resources/Payment Schedule.htm DCF requires all grants to be paid through an Automatic Clearing House payment(direct deposit). ACH payments will be deposited into your agency's account according to your agency's contract terms.To begin receiving ACH payment,complete the ACH Set-Up form available at http://dwd.wisconsin.gov/core/forms.htm sign and submit to the address on the form. Submit a copy of your completed expenditure report to the Program Manager, Irina Ertl at Irina.ertl(cr�wisconsin.gov. Please submit your claim DIRECTLY through the DWD Bureau of Finance e-mail,to ensure your payment is processed: DCFDESFinanceGrants @wisconsin.gov.The Expenditure Report form is available at http://dwd.wisconsin.gov/core/forms.htm. Medical Report: For every individual whose screening is paid for by this contract, a copy of the documentation showing their eligibility must be placed in their medical record(either scanned into their electronic Wisconsin Electronic Disease Surveillance System(WEDSS) record or included in their paper file). Appropriate documentation could be: ❑ the individual's Arrival/Departure Record(form I - 94) ❑ A letter from the Office of Refugee Resettlement or a letter from an immigration judge that documents the patient's status T 608.267.3905 F 608.266.6836 dcf.wi.gov DCF-F-13-E (R.04/2011) Docuslgn Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A These documents will identify whether the patient's status is that of a Refugee,Asylee, Cuban/Haitian Entrant,Victim of Trafficking, an Amerasian, or Special Immigrant Visa holder. In order to document the health status of Wisconsin's refugee population, the Wisconsin Division of Public Health collects refugee health screening results.Your health screening contract requires reporting of screening results to the Division of Public Health, Department of Health Services through WEDSS. Upon completion of screening, results must be entered into WEDSS'Wisconsin Initial Refugee Health Assessment form found in Nurse Case Manager. Screening results must be entered no later than 4 months post US arrival for all refugees screened. (For secondary migrants and asylees who are screened at your site, results should be submitted within 4 months of the initial date of screening.) Holders of the refugee health screening contract are required to ensure all recommended screening is complete as appropriate for every refugee. Training is available for all aspects of the refugee health assessment. Because HIV screening is no longer done overseas, HIV screening must be offered to all refugees ages 13 to 64. Oral health screening is now required for all holders of the refugee health screening contract. Lisa Bell(lisa.bell @wisconsin.gov),Wisconsin's Oral Health Consultant is available to provide training to staff on conducting an easy and short oral health screening. During the next three years,the State Refugee Program Section of the Department of Children and Families will develop a network of oral care providers to which RMA-eligible refugees can be referred for follow-up care. This year we will provide two webinar trainings related to refugee health.At least one refugee health team member from your health department must participate in the webinar or review the archived webcast.A survey will be sent to your office requesting ideas for content to ensure the sessions are as helpful and informative as possible. Questions regarding the Refugee Health Assessment, the screening form or screening results data collection should be directed to Savitri Tsering at 608/267-3733 or e-mail at savitri.tsering(Twisconsin.gov. Trimester Activity Reports: In accordance with the Refugee Health Screening and Education program contract,submit a trimester report of the numbers served in each of the following service categories; along with a narrative description of the refugee clients/activities/services provided: ❑ Screening(full or partial) and follow-up provided; ❑ Outreach services; ❑ Clients with Class A or Class B medical conditions provided follow-up and treatment; ❑ Medical interpreter services during the screening and follow-up; and ❑ Other Public Health services provided. In the program trimester service report,please include information on health education which you provided to refugees. This information should include the number and topics of the workshops or individual consultations, and how many refugees attended these workshops or received the individual consultations. Please send your reports to irina.ertl @wisconsin.gov, or U.S. mail at 201 E.Washington Ave., Room A200, P.O. Box 8916,Madison,WI 53708-8916. We look forward to working with you and appreciate the quality of care that you provide to Wisconsin's refugee population. Sincerely, Irina Ertl, Refugee Health Program Manager Bureau of Working Families DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A wisconsin department of Governor Scott Walker children&families Secretary Eloise Anderson Bureau of Finance 201 E.Washington Ave., Room A200 PO Box 8916 Madison,WI 53708-8916 CONTRACT by and between Wisconsin Department of Children and Families and City of Oshkosh, Health Services Division PACKET NO: 331 COMMODITY OR SERVICE and DEFINITION: The purpose of this agreement is to purchase from the Provider health screening and public health services authorized under Chapter 2 of Title IV of the Immigration and Nationality Act as amended by PL 97-363 and PL 99- 605.Description of program/service Contract Period: FUNDING PERIOD: October 1, 2011—September 30, 2012 October 1, 2011—September 30, 2012 DCF Program Administration: Contract Billing and Payment Terms Irina Ertl—Phone#608 266-8354 Due on/before 20th—Paid Last Business Day Irina.Ertl@wisconsin.gov CONTRACTOR INFORMATION: Contractor/Provider Name: City of Oshkosh, Health Services Division Contractor/Provider Authorized Representative: Jayne Tebon Contractor/Provider Authorized Email: jtebon @ci.oshkosh.wi.us Contractor/Provider Address: 215 Church Ave. Contractor/Provider City, State,Zip: Oshkosh, WI 54901 Contractor/Provider Phone/Fax: 920.236.5035/ Contractor/ Provider Administrator: Jayne Tebon Contractor/Provider Email: 1 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A Contractor: CORe Agency Code#: Contract#331 City of Oshkosh, Health Services Division RQ Funding Period: October 1, 2011—September 30, 2012 CORe Contract Current Contract Total Contract Commodity or Service Description Code Number Amount Contract Change Balance Refugee Health Screening 7309 $29,300.00 $29,300.00 The Department and the Contractor acknowledge that they have read the Contract and the attached exhibits, addendums and requirements, understand them and agree to be bound by their terms and conditions. Further, the Department and the Contractor agree that the Contract and the exhibits and documents incorporated herein by reference are the complete and exclusive statement of the agreement between the parties relating to the subject matter of the Contract and supersede all proposals, letters of intent or prior agreements, oral or written, and all other communications and representations between the parties relating to the subject matter of the Contract. DCF reserves the right to reject or cancel agreements based on documents that have been altered. This Agreement becomes null and void if the time between the earlier dated signature and the later dated signature exceeds sixty(60) days, unless waived by the Department. Signatures .--Dcc11s aned br. `44 ‘64.0 081A, 11/1/2011 �..—F1FORre,Frnaa1 R Authorized Representative Signature Date • Denise Krueger RN, Interim Health officer Name,Title kris pvw,clal. 10/5/2011 Kristiane Randal, Division of Family& Economic Security • Date Division Administrator 10/5/2011 •-13A461421131 OGt B.. Joan Hansen, Department of Children and Families Date Deputy Secretary • 2 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A I. PARTIES TO THE CONTRACT This contract, hereinafter referred to as the "Contract", shall be between the Wisconsin Department of Children and Families, hereinafter referred to as DCF, and the contractor listed on the signature pages, hereinafter referred to as "contractor" and/or"Provider" for the procurement of Commodity or Services listed, according to the terms set forth in this Contract. The Contractor shall not have exclusive rights to provide all supplies or services covered under this contract during the term of the contract or any extension of the contract. II. EXECUTED CONTRACT TO CONSTITUTE ENTIRE CONTRACT DCF's Request for Proposal, the proposal response,written communications and this Contract constitute the entire contract between the parties. The hierarchy of documents in order for resolution is as follows. A. Laws, regulations and policies of the State and Federal government B. Official Wisconsin Department of Children and Families Purchase Order and/or Contract(Standard Terms and Conditions attached to any of these procurement documents govern unless modified within the document) C. Written communications regarding contract terms agreed upon in writing D. Contractor's Proposal as submitted Any conflict in terms shall be governed by the highest listed document. Contractor composed and submitted contracts will not be accepted as a substitute for these terms and conditions. Contractor agrees to renegotiate this contract or any part thereof in such circumstances as • increased or decreased volume of services • changes required by State and Federal law or regulations, or court action • reduction in the monies available affecting the substance of this Contract Failure to agree to a renegotiated contract under these circumstances is cause for DCF to terminate this contract. Revision of this contract may be made by mutual contract. The revision will be effective only when the DCF and the Contractor attach an addendum or amendment to this contract which is signed by the authorized representatives of both parties, except in circumstances in which increased caseload or contract amount, where such increase in funds is for the same purpose as originally agreed upon,the contract may be amended by a unilateral amendment made by the DCF. Ill. SCOPE OF SERVICES The Contractor will provide refugee health screening and public health services in accordance with this contract. The agency will seek to have each patient complete a release of information form in accordance with HIPAA regulations, in order to facilitate coordination of health education and care with the voluntary resettlement agency. Whenever authorized by the patient,the Health Screening Service provider will inform the agency of resettlement about the health condition of each individual screened for follow-up care. The screening agency will also coordinate health education activities with the local voluntary agency. Local public health agencies will be eligible for reimbursement for the following public health services when provided to eligible refugees, entrants, asylees, certified victims of human trafficking and any other individuals eligible under refugee medical programs. 3 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A Outreach and Health Education These activities assure that refugees obtain initial health assessments and health education services by a public or private provider. Services are reimbursable once the agency verifies that the refugee has received an assessment and health education services within 90 days of arrival in the United States. The agency will contact at least 70%of new arrivals within 90 days of arrival. Outreach health education services include individual consultations covering: • assessment of patient's understanding and awareness of basic health and hygiene in America • basic information on health screening and immunization • identification of a clinic for patient's ongoing health care Screening and Follow-up Screening and follow-up shall include all tests,exams, immunizations and follow-up recommended in the protocol approved by the Office of Refugee Resettlement when performed within 90 days of arrival in the United States. The provider shall include individual consultations regarding: • results of health screening and the importance of follow-up appointments • prescription medications and over-the-counter medications appropriate for his/her needs Other Public Health Services The health screening clinics shall provide where indicated other public health services normally available to indigent state residents at public expense by a public agency include: • follow-up care and testing for conditions identified in an initial assessment for such communicable diseases as tuberculosis (TB), hepatitis and parasites • TB prophylaxis • immunizations • health education to acquaint refugees with the health care delivery system and risk reduction techniques • reproductive health, including family planning • hepatitis B identification, education and inoculation • prenatal care education, nutrition education, and other healthy birth initiatives designed to increase birth weights and assure healthy deliveries among at-risk groups Interpretation Services Interpretation services to be provided to non-English speaking and limited English proficient clients during their screenings,follow-up, and health education. 4 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A Expected Number to be Served: Estimated Number Estimated Amount Estimated Total of Clients per Client Outreach 50 $ 50 per client $2,500.00 Outreach Follow-Up 0 $200 per client 0 Screening and Follow-Up N/A $400 per client $0.00 Partial Screening and Follow-Up 50 $ 200 per client $10,000.00 Other Public Health Services 30 hr $60 per hour $1,800.00 Interpretation Services 250 hr $60 per hour $15,000.00 Estimated Program total cost $29,300.00 Program Assurances A. The Provider will verify and document that all clients served under this contract are refugees or asylees as defined in the Immigration and Nationality Act. B. The Provider is eligible for reimbursement for outreach, health screening, and related health education services only if the refugee has been in the country for 90 days or less on the date of service,or the asylee was granted asylum no more than 90 days prior to the date of service. C. The Provider is eligible for reimbursement for other public health services only if the refugee is eligible for Refugee Medical Assistance on the date of service. Provider Requirements The Provider shall administer the health screening program according to the directives of the Purchaser including those contained in or amended during the period of the contract, and: A. all applicable state and federal laws, rules and regulations B. the State Refugee Services Plan and Screening Protocol as approved by the Administration for Children and Families of the U.S. Department of Health and Human Services C. applicable Department administrative rules Reporting and Monitoring The Provider shall submit a trimester report of the number served in each of the following service categories on the form provided. - A. Outreach B. Screening and assessment C. Clients with Class A or Class B medical conditions provided follow-up and treatment D. Other public health services provided to Refugee Medical Assistance clients E. Interpretation services during health screenings and follow-up 5 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A This report will be submitted to the Purchaser's contract administrator within 15 days of the close of each trimester. Reports are due February 15, 2012,June 15, 2012 and October 15, 2012. The Provider shall submit a report of the screening results to the Bureau of Communicable Diseases of the Wisconsin Division of Public Health within thirty(30) days following the completion of each screening. The Provider will also submit to the Purchaser a report evaluating its Refugee Health Program within 90 days of the end of this contract. IV. BILLING AND PAYMENT TERMS Awarded contract will follow the costs outlined in Program Budget. Progress payments will be made from properly submitted invoices, each month,for rendered services. A. Allowable Costs The Department will make payments for costs that are consistent with the DCF Allowable Cost Policy Manual and applicable federal allowable cost policies. Program expenditures and descriptions of allowable costs are further described in 2 CFR Part 225 (formerly OMB Circular A-87)and Part 230 (formerly OMB Circular A-122)or the program policy manual. See Office of Management and Budget website for links to Code of Federal Regulations (CFR) sections: http://www.whitehouse.gov/omb/circulars default B. Excess/Overpayments The Contractor will return to DCF any funds paid in excess of the allowable costs of services provided under this contract within 30 days of notification by DCF. Allowable costs are defined by OMB Circulars A-87,A-122 and A-21,the attachment(s) to this contract, and/or the program policy manual. If the Contractor fails to return funds paid in excess of the allowable costs of the services provided, DCF may recover any funds paid in excess of the conditions of this contract from subsequent payments or may recover such funds by any legal means. C. Payments 1. Payments will be made monthly based on expense reports submitted by the Grantee on The Grantor's Central Office Reporting(CORe) system. The Department shall maintain reporting support and provide access to instructions and forms via http://dcf.wisconsin.gov/contractsgrants/. Claims for reimbursement of allowable costs shall be submitted to the Department not later than the 20`h day of the month following the month in which costs are incurred. The Grantee shall report, by Grantor assigned profile number, all allowable costs plus any required matching funds stipulated in the reporting instructions for this Grant which are incorporated by reference. See Allowable Cost Policy Manual. During the term of this contract, the Department shall use the Allowable Cost and Financial Management Manuals (http://dcf.wisconsin.gov/contractsgrants/pdf/allowable cost manual.pdf) Development of DCF manuals for these and other existing DHS manuals used in this and in previous contracts shall replace their DHS counterparts as they are created. The Financial Management and the Allowable Cost Policy Manuals can be viewed on the Department of Children and Families Internet web site at http://dcf.wisconsin.gov when they become available. 2. Claims for reimbursement will be submitted electronically(emailed)to: DCFDESFinanceGrants @wisconsin.gov The Expenditure Report form is available at http://dwd.wisconsin.gov/core/forms.htm. 6 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A 3. The Expenditure Report must be submitted to the Purchaser by close of business (4:30 pm CT)on or before the 20th day of the month following the month for which reimbursement is being claimed. The Department will issue the reimbursement using direct deposit on the 30th day of the same month, subject to reduction, recovery and reimbursement as provided in this Contract. Late reports will be processed in the next month's payment cycle. If the 20th day of the month and/or the 30th day of the month fall on a non-business day (per the State of Wisconsin calendar),the Expenditure Report due date and/or reimbursement date become the next business day. The payment schedule is available on the CORe website: http://dwd.wisconsin.gov/CORe/resources/Payment Schedule.htm 4. DCF requires all grants to be paid through an Automatic Clearing House payment(direct deposit). ACH payments will be deposited into your agency's account according to your agency's contract terms. To begin receiving ACH payment, complete the ACH Set-Up form available at http://dwd.wisconsin.gov/core/forms.htm sign and submit to the address on the form. 5. The Department cannot pay Expenditure Reports that are incomplete. Expenditure Reports that do not contain all required information will be returned to the agency to be completed and resubmitted. Resubmitted claims will be paid with the next regular payment cycle. It is important to fill in all fields, with the CORe Agency Number and the Reporting Period: both month and year, being the most critical. See form details for appropriate file naming conventions. a. Final Expenditure Report The Provider shall submit all claims for reimbursement under this Contract to the Department within 90 days of the end of the period as specified in each Appendix. Expenses incurred within this Contract period and reported later than ninety (90)days will not be recognized, allowed or reimbursed under the terms of this Contract. b. Return of the Excess Payments The Provider will return to the Purchaser any funds paid to the Provider in excess of the allowable costs of services provided under this contract within 30 days of notification by the Purchaser. Allowable costs are defined by OMB Circulars A-87, A- 122 and A-21,which can be located at http://www.whitehouse.gov/omb/circulars default/and/or the program policy manual. If the Provider fails to return funds paid in excess of the allowable costs of the services provided,the Purchaser may recover any funds paid in excess of the conditions of this contract from subsequent payments or may recover such funds by any legal means. All payments shall be released by the Department on the last working day of each month, with the exception that the payment that would normally be released on the last working day of June shall be released instead on the first working day of July. For municipalities, payment shall be mailed by the last working day or the 5th of the month. Checks will be mailed to the Grantee's principal business address unless the Grantee requests, in writing, subject to approval, that the Department mail the checks to a different address. (The Department is planning to modify some aspects of its current payment mechanism so that in the future it can accommodate making payments via electronic funds transfer. 7 DocuSIgn Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A D. Withholding and Deduction of Funds 1. Withholding The Department shall have the right to withhold any and all payments due the Contractor if the Contractor fails to provide services consistent with this Contract; if the Contractor fails to meet a provision of this Contract; or if the Department reasonably determines it to be necessary to protect the Department against potential losses or liabilities, including potential Federal disallowances or sanctions. The payments to be withheld will be in an amount the Department determines necessary to cause the Contractor to correct its failures or to protect the Department against potential losses or liabilities, and such amount will be withheld until the failure to provide the services or meet the Contract provision is cured or until the potential loss or liability ceases. The Department will withhold funds pursuant to this subsection only after the Department has given notice to withhold funds and where the reasons for withholding continue after 30 days of such notification. The Contractor's failure to meet the performance standards may subject the Contractor to the withholding and deduction provisions authorized under this Contract. 2. Deduction/Reduction of Funds The Department makes payments only for services that are actually provided and that meet the terms and conditions of this Contract.Therefore,the Department shall have the right to deduct the amounts being withheld from its financial obligations to the Contractor if, at the end of the Contract term, the Contractor has not yet cured its failures or caused the potential losses or liabilities to cease. In addition,the Department shall have the right to deduct amounts equal to an amount imposed against the Department as a Federal disallowance or sanction that is attributable to the Contractor's performance or failure to perform. The Department shall have the right to deduct any amounts due the Department from the Contractor from money otherwise payable to the Contractor for any other reason specifically provided under this Contract. The DCF reserves the right, upon careful examination,to reduce the total amount of the contract award due to significant under-spending by the Contractor. All such contract award reductions will become effective upon thirty(30) days written notice to the Contractor and shall not relieve the Contractor of any programmatic requirements. E. Contractor Liabilities 1. Past Due Liabilities The Contractor shall notify the DCF in writing,within thirty(30) days of the date payment was due of any past due liabilities to the Federal government,State government or their agents for income tax withholding, FICA, Workers' Compensation, Unemployment Compensation,garnishments or other employee related liabilities, Sales Tax, Income Tax of the Contractor,or other monies owed. The written notice shall include the amount(s) owed,the reason the monies are owed,the due date,the amount of any penalties or interest, known or estimated, the unit of government to which the monies are owed, the expected payment date and other related information. 8 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A 2. Past Due Payments The Contractor shall notify the DCF, in writing,within thirty (30)days of the date payment was due, of any past due payment in excess of five hundred dollars($500), or when total past due liabilities to any one or more Contractors exceed one thousand dollars ($1000), related to the operation of this Contract for which the DCF has reimbursed or will reimburse the Contractor. The written notice shall include the amount(s)owed,the reason the monies are owed,the due date,the amount of any penalties or interest, known or estimated, the Contractor to which the monies are owed, the expected payment date and other related information. If the liability is in dispute, the written notice shall contain a discussion of facts related to the dispute and the information on steps being taken by the Contractor to resolve the dispute. VI. STATE AND FEDERAL RULES AND REGULATIONS A. Applicable Laws The Contractor shall comply with all federal and state laws, rules and regulations and with Policies and Procedures relating to the provision of services under this Contract. B. Health Insurance Portability&Accessibility Act(HIPAA)Requirements As a condition of receiving a contract from the State,the Contractor, and any Subcontractor(s),will be required to comply with 42 U.S.C.Sections 1320d through 1320d-8, and to implement regulations at 45 C.F.R.Section 164.502 (e)and Sections 164.504(e) regarding disclosure of protected health information under the Health Insurance Portability and Accountability Act (HIPAA)of 1996. Protected Health Information (PHI) is information received by the contractor from or on behalf of the State that meets the definition of PHI as defined by HIPAA and the regulations promulgated by the United States Department of Health & Human Services, specifically 45 CFR164.501 and any amendments thereto. • HIPAA compliance requires, at minimum, that the Contractor: 1) Shall not use or disclose PHI except as specifically required under the terms of the contract with the State,or as otherwise required under the HIPAA regulations or other applicable law. 2) Shall use appropriate safeguards to protect against use or disclosure not provided for by this Contract. 3) Shall promptly report to the State any knowledge of uses or disclosures of PHI that are not in accordance with the contract or applicable law. In addition,the Contractor shall mitigate any adverse effects of such a breach to the extent possible. 4) Shall ensure that all its agents and subcontractors that receive PHI from or on behalf of the contractor and/or the State agree to the same restrictions and conditions that apply to contractor with respect to the use or disclosure of PHI. 5) Shall make available to the State such information as the State may require to fulfill its obligations to provide access to, provide a copy of, and account for disclosures with respect to PHI pursuant to HIPAA and related regulations. 6) Shall make PHI available to the State in order for the State to fulfill its obligations pursuant to HIPAA to amend the information and shall, as directed by the State, incorporate any amendments into the information held by the contractor and ensure incorporation of any such amendments into information held by its agents or subcontractors. 7) Shall make available its internal practices, books and records relating to the use and disclosure of PHI received from the State, or created and received by the contractor 9 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A on behalf of the State, to the State and to the Secretary of the U.S. Department of Health and Human Services for the purpose of determining the State compliance with HIPAA and the regulations promulgated by the United States Department of Health & Human Services and any amendment thereto. 8) Shall, upon termination of this Contract, at the option of the State, return to the State, or destroy, all PHI in its possession, and keep no copies of the information except as requested by the State or required by law. If the contractor or its agent or subcontractors destroy any PHI,then the contractor will provide the State with documentation evidencing such destruction. Any PHI maintained by the contractor shall continue to be extended the same as required by HIPAA and the State for as long as it is maintained. 9) In the event of a material breach of contractor obligations under this section,the State may at its option terminate the contract according to provisions within the contract for termination. C. Civil Rights Compliance (CRC) Requirements The Contractor agrees to meet state and federal Civil Rights Compliance (CRC) laws, requirements, rules and regulations, as they pertain to the services covered by this contract. The website with Instructions and Templates necessary to complete both your CRC Letter of Assurance (LOA)and CRC Plan to meet civil rights compliance requirements is located at: http://dhs.wisconsin.gov/civilrights/CRC/requirements.htm The process by which the Contractor will ensure compliance with the CRC Requirements has changed from previous years.Additional resources and training information is available at: http://dcf.wisconsin.gov/civil rights/default.htm 1. Civil Rights Compliance Plan A Civil Rights Compliance (CRC) Plan is required to be completed by any Agency that has twenty-five(25)or more employees and receives a total of$25,000 or more in total government funding from Department of Children and Families (DCF),the Department of Health Services(DHS) and/or the Department of Workforce Development(DWD). The CRC Plan must be developed and completed in accordance with the instructions provided in the CRC Requirements document at the link above. The CRC Plan is to be completed and must be kept on file at the Agency. It is not to be submitted to the Department of Children and Families. This is a change from previous CRC Plan requirements. All CRC Requirements must be met, including the training of all agency staff and the posting of all required notices, prior to the submittal of the Letter of Assurance (LOA) required below. 2. Letter of Assurance(LOA): The Contractor is required to submit a Letter of Assurance(LOA)to ensure that the contractor has implemented state and federal Civil Rights Compliance (CRC) laws, requirements, rules and regulations, as they pertain to the services covered by this contract, and as a condition for receiving federal and/or state financial assistance from DCF. http://www.dhs.wisconsin.gov/forms/F0/f00165.doc. The Contractor, regardless of size, must complete a Civil Rights Compliance LOA to the Department's Civil Rights Compliance Unit. 10 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A The LOA must be completed and submitted to the Department within 180 days of signed contract. Send your completed LOA to: Equal Opportunity Officer Civil Rights Compliance Unit Department of Children and Families 201 E.Washington Avenue, Room G200 PO Box 8916 Madison, WI 53708-8916 D. Non-Discrimination/Affirmative Action Requirements In connection with the performance of work under this contract, the Contractor agrees not to discriminate against any employee or applicant for employment because of age, race, religion, color, handicap, sex, physical condition, developmental disability as defined in s. 51.01 (5), sexual orientation or national origin.This provision shall include, but not be limited to, the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. Except with respect to sexual orientation,the contractor further agrees to take affirmative action to ensure equal employment opportunities. 1. Written Plan Contracts that are twenty-five thousand dollars ($25,000) or more require the submission of a written Affirmative Action (AA) Plan by the Provider. An exemption from this requirement occurs if the Provider has a workforce of less than twenty-five(25) employees. Within thirty (30)calendar days of signing this Contract, the Provider must submit the Plan to the Department for approval. Instructions for preparing the Affirmative Action Plan are available on the WI Department of Administration website at: http://Contractornet.state.wi.us/Contractornet/contract/contcom.asp Your written plan or any questions should be submitted to the following: Department of Children and Families Bureau of Finance Director 201 E. Washington Ave., Room A200 PO Box 8916 Madison, WI 53708-8916 • 2. Posting of Notice The Agency agrees to post in conspicuous places, available for employees and applicants for employment, a notice to be provided by the Department that sets forth the provisions of the State of Wisconsin's non-discrimination law. 3. Failure to Comply Failure to comply with the conditions of this Non-Discrimination/Affirmative Action section may result in the Agency becoming declared "ineligible", termination of the Contract or withholding of payment. 11 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A F. Records The Contractor shall maintain such records (in either written or electronic form)as required by State and Federal law and as required by program policies. Records shall be retained for no less than the retention period specified in law or policy. Records for periods which are under audit or subject to dispute or litigation must be retained until the audit/dispute/litigation, and any associated appeal periods, have ended. Contractor will allow inspection of records and programs, insofar as is permitted by State and Federal law, by representatives of DCF and its authorized agents, and Federal agencies, in order to confirm Contractor's compliance with the specifications of this Contract. Contractor agrees to retain and make available to DCF all program and fiscal records in accordance with the retention period specified in section A above. Upon DCF's request, at the expiration of the contract,the Contractor will transfer at no cost to DCF records regarding the individual recipients who received services from Contractor under this Contract.The transfer of records includes transfer of any record, regardless of media, if that is the only method under which records were maintained. Contractor and its subcontractors shall comply with all state and federal confidentiality laws concerning the information in both the records it maintains and in any of DCF's records that Contractor accesses to provide the services under this Contract. VII. PRIVACY AND CONFIDENTIAL INFORMATION Confidentiality The Contractor shall not use Confidential Information for any purpose other than the limited purposes set forth in this Contract, and all related and necessary actions taken in fulfillment of the obligations there under.The Contractor shall hold all Confidential Information in confidence, and shall not disclose such Confidential Information to any persons other than those directors,officers, employees, and agents ("Representatives")who have a business-related need to have access to such Confidential Information in furtherance of the limited purposes of this Contract and who have been apprised of, and agree to maintain, the confidential nature of such information in accordance with the terms of this Contract. Contractor shall institute and maintain such security procedures as are commercially reasonable to maintain the confidentiality of the Confidential Information while in its possession or control including transportation, whether physically or electronically. Contractor shall ensure that all indications of confidentiality contained on or included in any item of Confidential Information shall be reproduced by Contractor on any reproduction, modification, or translation of such Confidential Information. If requested by the State, Contractor shall make a reasonable effort to add a proprietary notice or indication of confidentiality to any tangible materials within its possession that contain Confidential Information of the State, as directed. If requested by the State, Contractor shall return or destroy all Individually Identifiable Health Information and Personally Identifiable Information it holds upon termination of this contract. Definitions used herein: "Confidential Information" means all tangible and intangible information and materials accessed or disclosed in connection with this Contract, in any form or medium (and without regard to whether the information is owned by the State or by a third party),that satisfy at least one of the following criteria: (i) Personally 12 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A Identifiable Information; (ii) Individually Identifiable Health Information; (iii) non-public information related to the State's employees,customers,technology(including data bases, data processing and communications networking systems), schematics, specifications, and all information or materials derived there from or based thereon; or(iv) information designated as confidential in writing by the State. "Individually Identifiable Health Information" means information that relates to the past, present,or future physical or mental health or condition of the individual, or that relates to the provision of health care in the past, present or future, and that is combined with or linked to any information that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual. "Personally Identifiable Information"means an individual's last name and the individual's first name or first initial, in combination with and linked to any of the following elements, if the element is not publicly available information and is not encrypted, redacted, or altered in any manner that renders the element unreadable: (a)the individual's Social Security number; (b) the individual's driver's license number or state identification number; (c)the number of the individual's financial account, including a credit or debit card account number,or any security code, access code, or password that would permit access to the individual's financial account; (d)the individual's DNA profile; or(e)the individual's unique biometric data, including fingerprint,voice print, retina or iris image, or any other unique physical representation, and any other information protected by state or federal law. VIII. ACCOUNTING REQUIREMENTS (GRANTS) A. Accounting Records The Contractor shall maintain accounting records in accordance with generally accepted accounting principles, in a manner which will enable state or federal.government or other staff to audit and examine any books,documents, papers and records maintained in support of the Contract and as more specifically provided below. All documents shall be made available to the Department at its written request, and shall be identifiable as pertaining to this Contract. B. Accounting System The Contractor shall maintain a uniform double entry,full accrual accounting system. The Contractor shall maintain a financial management information system in accordance with the Generally Accepted Accounting Principles contained in the Department's Allowable Cost Policy Manual. C. System Requirements The Contractor's accounting system shall allow for accounting for individual programs, permit timely preparation of expenditure reports and support expenditure reports submitted to the Department. D. Reconciling Reports The Contractor shall reconcile costs reported to the Department to expenses recorded in the Contractor's accounting system on an ongoing and periodic basis. The Contractor agrees that reconciliation will be completed at least quarterly and will be documented and supplied to the Department upon request. The Contractor shall retain the reconciliation documentation in accordance with record retention requirements. E. Accounting Period The Contractor's accounting records shall be maintained on a calendar year basis, beginning January 1 of each year, unless changed after prior approval from the Department. Approval will be given 13 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A only if the Contractor submits proof of Internal Revenue Service approval for changing the accounting period and if the Contractor agrees to submit a close-out audit for the shortened accounting period,within 90 days after the first day of the new accounting period. For purposes of determining audit requirements, expenses and revenues incurred during the shortened accounting period shall be annualized. F. Cost Allocation Plan The Contractor shall submit a copy of their cost allocation plan to the Department within 30 days of signing the contract.The plan must be reasonable, documented in writing in a Contractor-wide cost allocation plan and a Contractor wide indirect cost allocation plan.Costs must be allocated in a manner consistent with these plans.The plans must be in accordance with the requirements of applicable federal cost policies. VIX. AUDITING REQUIREMENTS A. Requirement to Have an Audit Unless waived by DCF, the Contractor shall submit an annual audit to DCF if the total amount of annual funding provided by DCF (from any and all of its Divisions taken collectively)through this and other contracts is$25,000 or more. In determining the amount of annual funding provided by DCF, the Contractor shall consider both: (a)funds provided through direct contracts with DCF; and (b) funds from DCF passed through another agency which has one or more contracts with the Contractor. B. Audit requirements The audit shall be performed in accordance with generally accepted auditing standards, s.49.34(4)(c), Wis.Stats., Government Auditing Standards, and other provisions in this contract. In addition, the Contractor is responsible for ensuring that the audit complies with other standards that may be applicable depending on the type of Contractor and the nature and amount of financial assistance received from all sources: • Federal OMB Circular A-133 "Audits of States, Local Governments and Nonprofit Organizations";which applies only to Contractors that expend $500,000 from all federal funding sources(this grant and other grants, direct or indirect, from this DCF or another), during a Contractor's fiscal year. • The State Single Audit Guidelines(SSAG), including the yearly Appendix,which are applicable to local governments having A-133 audits; and/or • The Provider Agency Audit Guide(PAAG). All Contractors which do not meet the requirements of the SSAG shall have audits in conformance with the PAAG. C. Source of funding Funding information needed for audit purposes includes the name of the program,the federal agency where the program originated, the CFDA number, and the percentages of federal, state, and local funds constituting this contract.This information can be supplied on the CORE Payment Information Form included with this contract. D. Reporting package The Contractor shall submit to DCF a reporting package which includes the following: 14 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A 1. Financial statements and other audit schedules and reports required for the type of audit applicable to the Contractor. 2. Summary schedule of prior year findings and the status of addressing these findings. 3. The Management Letter(or similar document conveying auditor's comments issued as a result of the audit)or written assurance that a Management Letter was not issued with the audit report. 4. Management responses/corrective action plan for each audit issue identified in the audit. E. Submitting the Reporting Package The Contractor shall submit the required reporting package to DCF either: (1)within 9 months of the end of the Contractor's fiscal year if the Contractor is a local government;or(2)within 180 days of the end of the Contractor's fiscal year for non-governmental Contractor agencies. DCF encourages electronic submission of the reporting package. Electronic Reporting Packages should be sent to: DCFAuditors @wisconsin.gov Hard copy Reporting Packages should be sent to: DCF Auditors Bureau of Finance, Division of Enterprise Solutions Department of Children and Families P.O. Box 8916 Madison, WI 53706-8916 Telephone: (608)264-6992 F. Access to auditor's work papers When contracting with an audit firm, the Contractor shall authorize its auditor to provide access to work papers, reports, and other materials generated during the audit to the appropriate representatives of the Department. Such access shall include the right to obtain copies of the work papers and computer disks, or other electronic media, upon which records/working papers are stored. G. Access to Contractor records The Contractor shall permit appropriate representatives of the Department and/or DCF to have access to the Contractor's records and financial statements as necessary to review Contractor's compliance with the federal and state requirements for the use of the funding. H. Failure to comply with the requirements of this section In the event that the Contractor fails to have an appropriate audit performed or fails to provide a complete audit report to DCF within the specified timeframes, in addition to applying one or more of the sanctions available in Section XVIII of this contract, DCF may: 15 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A 1. Conduct an audit or arrange for an independent audit of the Contractor and charge the cost of completing the audit to the Contractor; 2. Charge the Contractor for all loss of Federal or State aid or for penalties assessed to DCF because the Contractor did not submit a complete audit report within the required time frame;and/or 3. Disallow the cost of audits that do not meet these standards. Close-out Audits 1. A contract specific audit of an accounting period of less than twelve(12) months is required when a Contract is terminated for cause, when the Contractor ceases operations or when the Contractor changes its accounting period (fiscal year). The purpose of the audit is to close- out the short accounting period. The required close-out contract specific audit may be waived by DCF upon written request from the Contractor, except when the Contract is terminated for cause. The required close-out audit may not be waived when a Contract is terminated for cause. 2. The Contractor shall ensure that its auditor contacts DCF prior to beginning the audit. DCF, or its representative, shall have the opportunity to review the planned audit program, request additional compliance or internal control testing and attend any conference between the Contractor and the auditor. Payment of increased audit costs, as a result of the additional testing requested by DCF, is the responsibility of the Contractor. 3. DCF may require a close-out audit that meets the audit requirements specified in Section XIII, B above. In addition, DCF may require that the auditor annualize revenues and expenditures for the purposes of applying OMB Circular A-133 and determining major Federal financial assistance programs. This information shall be disclosed in a note to the schedule of Federal awards. 4. All other provisions in the Audit Requirements section apply to Close-out Audits unless in conflict with the specific Close-out Audits requirements. X. DEPARTMENT PROPERTY A. Records All case information, paper records, written information;and any electronic data shall remain confidential, as required by law and applicable policy, and shall be the sole property of the State of Wisconsin.The contractor must respond immediately to all inquiries from DCF and make all records and any written and/or electronic case information available to DCF at any time upon request. DCF, in its monitoring of the contract, reserves the right to inspect or investigate any and all contract and subcontract agency records, procedures, and operations at any time during and after the close of the contract period. B. Property The DCF shall have all ownership rights in any hardware funded under this Contract or supplied by the DCF and in any software or modifications thereof and associated documentation designed, developed or installed as a result of this Contract. The Contractor is responsible for keeping all of DCF's property secure from theft,damage or other loss. 16 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A The contractor shall preserve the safety, security and integrity of the personnel, premises, equipment, data and other property of the state, in accordance with the instruction of the state.The contractor shall be responsible for damage to the state's equipment,workplace and its contents, when such damage or loss is caused by the negligence or willful misconduct of contractor, contracted personnel or subcontractors, and shall reimburse the state accordingly upon demand. This remedy shall be in addition to any other remedies available to the state by law or in equity. Contractor shall surrender to DCF all State property upon the earliest of expiration or termination of this Contract. C. Proprietary Information Data contained in the proposal, all documentation provided therein, and materials and innovations developed as a result of this contract award cannot be copyrighted or patented without written authorization from DCF. All data, documentation, and innovation become the property of the State of Wisconsin and DCF. The successful applicant agrees that DCF shall have royalty-free, non- exclusive, and irrevocable rights to reproduce, publish, or otherwise use and authorize others to use any materials and innovations developed as a result of this contract award. Any copyright material authorized by DCF or distribution of materials developed through this contract award will acknowledge use of DCF funds. All right,title and interest in any items and materials originated or prepared specifically and exclusively for the State under the resulting contract from the time of payment belong to the State unless the State has previously agreed in writing to accept less than the ownership rights described here. All informational materials related to this contract will be branded using DCF approved materials including flyers, Power Point templates and other materials as designated by the Department. XI. SUBCONTRACTS A. Prior Written Approval The Contractor may subcontract part of this Contract only with the prior written approval of the DCF. In addition, DCF approval may be required regarding the award process,the terms and conditions of the subcontracts and the subcontractors selected. Approval of the subcontractors will be withheld if the DCF reasonably believes that the intended subcontractor will not be a responsible provider in terms of services provided and costs billed. B. Contractor Responsibility The Contractor retains responsibility for fulfillment of all terms and conditions of this Contract when it enters into sub-contractual contracts and will be subject to enforcement of the terms and conditions of this Contract. C. Minority Business Subcontractors The Wisconsin Department of Children and Families is committed to the promotion of minority businesses in the State's purchasing program. Authority for this program is found in Wisconsin Statutes 15.107(2), 16.75(3m),and 16.755. Contractor is strongly urged to use due diligence to further this policy by setting up subcontracts to state-certified Minority Business Enterprises(MBE) and/or by using such enterprises to provide goods and services incidental to this contract(second-tier suppliers), with a goal of awarding 5%of 17 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A the contract cost to such enterprises. An MBE means a business certified, or certifiable, by the Wisconsin Department of Commerce under Statute 560.036(2). XII. DISPUTE RESOLUTION If any dispute arises between DCF and Contractor under this contract, including DCF's finding of non- compliance and imposition of sanctions or remedial measures, the following process will be the exclusive administrative review. A. DCF's and Contractor's Contract Administrators will attempt to resolve the dispute. B. If the dispute cannot be resolved by the Contract Administrators, Contractor may ask for review by the Administrator of the Division in which the DCF's Contract Administrator is employed,or if the Contract Administrator is the Administrator of the Division, by the Deputy Secretary of the Department. If the dispute is still not resolved, Contractor may request a final review by the Secretary of the Department. XIII. NON-COMPLIANCE, SANCTIONS AND REMEDIAL MEASURES A. Failure To Comply Failure to comply with any part of this contract may be considered cause for revision, suspension or termination of this contract. Suspension includes withholding part or all of the payments that otherwise would be paid the Contractor under this contract,temporarily having others perform, and receive reimbursement for, the services to be provided under this contract and any other measure that suspends the Contractor's participation in the contract if the DCF determines it is necessary to protect the interests of the State. B. Written Notice for Non-compliance The Contractor shall provide written notice to the DCF of all instances of non-compliance with the terms of this contract by itself or its subcontractors, including non-compliance with allowable cost provisions. Notice shall be given as soon as practicable but in no case later than 30 days after the Contractor knows, or should have known, about the non-compliance. The written notice shall include information on reason(s)for and effect(s)of the non-compliance. Contractor shall provide DCF with a plan to correct the non-compliance. At its sole discretion,the DCF may take whatever action it deems necessary to protect the interests of the State, including withholding part or all of Contractor's funding, if it reasonably believes that the non-compliance is continuing or will reoccur. C. Immediate Correction If DCF determines that non-compliance with the requirements in this contract has occurred, or is occurring, it shall demand immediate correction of continuing non-compliance and it may impose whatever sanctions or remedial measures it deems necessary to protect the interests of the State. Such sanctions and measures may include termination of the contract, suspension of the contract as defined in A. above, imposing additional reporting requirements and monitoring of subcontractors and any other measures it deems appropriate and necessary. D. Withholding of Payments If required statistical data, reports and other required information,other than audits, are not submitted when due, DCF may withhold all payments that otherwise would be paid the Contractor under this contract until such time as the reports and information are submitted. 18 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A E. Notice to DCF The Contractor shall notify the DCF whenever it is unable to provide the required quality or quantity of services specified. Upon such notification, the DCF shall determine whether such inability will require revision or termination of this contract. XIV. CANCELLATION AND TERMINATION A. Termination for Cause The State may terminate this Contract after providing the Contractor with thirty(30)calendar days written notice of the Contractor's right to cure a failure of the Contractor to perform under the terms of this Contract. The Contractor may terminate this Contract after providing the State one hundred and twenty(120) calendar days' notice of the State's right to cure a failure of the State to perform under the terms of this Contract. Upon the termination of this Contract for any reason, or upon Contract expiration, each party shall be released from all obligations to the other party arising after the date of termination or expiration, except for those that by their terms survive such termination or expiration. B. Termination for Convenience Either party may terminate this Contract at any time, without cause, by providing a written notice; the State by providing at least thirty(30)calendar days' notice to the Contractor, and the Contractor providing at least one hundred and twenty(120) calendar days' notice to the State in advance of the intended date of termination. In the event of termination for convenience, the Contractor shall be entitled to receive compensation for any fees owed under the Contract.The Contractor shall also be compensated for partially completed Services. In this event, compensation for such partially completed Services shall be no more than the percentage of completion of the Services requested, at the sole discretion of the State, multiplied by the corresponding payment for completion of such Services as set forth in the Contract. Alternatively, at the sole discretion of the State, the Contractor may be compensated for the actual Service hours provided. The State shall be-entitled to a refund for goods or services paid for but not received or implemented, such refund to be paid within 30 days of written notice to the Contractor requesting the refund. C. Contract Cancellation The State reserves the right to cancel this Contract in whole or in part without penalty if the Contractor: • Breaches or defaults an obligation under the Contract as follows: - Fails to perform any material obligation required under the Contract - Files a petition in bankruptcy, becomes insolvent,or otherwise takes action to dissolve as a legal entity - Allows any final judgment not to be satisfied or a lien not to be disputed after a legally- imposed, 30-day notice. - Makes an assignment for the benefit of creditors 19 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A • Fails to follow the sales and use tax certification requirements of s. 77.66 of the Wisconsin Statutes; • Incurs a delinquent Wisconsin tax liability; • Fails to submit a non-discrimination or affirmative action plan as required here in. • Fails to follow the non-discrimination or affirmative action requirements of such. II, Chapter 111 of the Wisconsin Statutes(Wisconsin's Fair Employment Law); • Becomes a federally debarred Contractor; • Is excluded from federal procurement and non-procurement Contracts; • Fails to maintain and keep in force all required insurance, permits and licenses as provided in this Contract • Fails to maintain the confidentiality of the State's information that is considered to be Confidential Information, proprietary, or containing Personally Identifiable Information, or • Contractor performance threatens the health or safety of a State employee or State customer. 20 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A STANDARD TERMS&CONDITIONS,DOA-3054(R10/2005) 1.0 SPECIFICATIONS: The specifications in this request are the minimum acceptable. When specific manufacturer and model numbers are used, they are to establish a design,type of construction, quality, functional capability and/or performance level desired. When alternates are bid/proposed, they must be identified by manufacturer, stock number, and such other information necessary to establish equivalency. The State of Wisconsin shall be the sole judge of equivalency. Bidders/proposers are cautioned to avoid bidding alternates to the specifications which may result in rejection of their bid/proposal. 2.0 DEVIATIONS AND EXCEPTIONS: Deviations and exceptions from original text, terms, conditions, or specifications shall be described fully, on the bidder's/proposer's letterhead, signed, and attached to the request. In the absence of such statement, the bid/proposal shall be accepted as in strict compliance with all terms,conditions,and specifications and the bidders/proposers shall be held liable. 3.0 QUALITY: Unless otherwise indicated in the request,all material shall be first quality. Items which are used,demonstrators,obsolete,seconds,or which have been discontinued are unacceptable without prior written approval by the State of Wisconsin. 4.0 QUANTITIES: The quantities shown on this request are based on estimated needs. The state reserves the right to increase or decrease quantities to meet actual needs. 5.0 DELIVERY: Deliveries shall be F.O.B.destination freight prepaid and included unless otherwise specified. 6.0 PRICING AND DISCOUNT: The State of Wisconsin qualifies for governmental discounts and its educational institutions also qualify for educational discounts. Unit prices shall reflect these discounts. • 6.1 Unit prices shown on the bid/proposal or contract shall be the price per unit of sale(e.g.,gal.,cs.,doz.,ea.)as stated on the request or contract. For any given item,the quantity multiplied by the unit price shall establish the extended price,the unit price shall govern in the bid/proposal evaluation and contract administration. 6.2 Prices established in continuing agreements and term contracts may be lowered due to general market conditions, but prices shall not be subject to increase for ninety(90)calendar days from the date of award. Any increase proposed shall be submitted to the contracting agency thirty(30)calendar days before the proposed effective date of the price increase, and shall be limited to fully documented cost increases to the contractor which are demonstrated to be industry wide. The conditions under which price increases may be granted shall be expressed in bid/proposal documents and contracts or agreements. 6.3 In determination of award,discounts for early payment will only be considered when all other.conditions are equal and when payment terms allow at least fifteen(15)days,providing the discount terms are deemed favorable. All payment terms must allow the option of net thirty(30). 7.0 UNFAIR SALES ACT: Prices quoted to the State of Wisconsin are not governed by the Unfair Sales Act. 8.0 ACCEPTANCE-REJECTION: The State of Wisconsin reserves the right to accept or reject any or all bids/proposals,to waive any technicality in any bid/proposal submitted,and to accept any part of a bid/proposal as deemed to be in the best interests of the State of Wisconsin. Bids/proposals MUST be date and time stamped by the soliciting procurement office on or before the date and time that the bid/proposal is due. Bids/proposals date and time stamped in another office will be rejected. Receipt of a bid/proposal by the mail system does not constitute receipt of a bid/proposal by the procurement office. 9.0 METHOD OF AWARD: Award shall be made to the lowest responsible,responsive bidder unless otherwise specified. 10.0 ORDERING: Purchase orders or releases via purchasing cards shall be placed directly to the contractor by an authorized agency. No other purchase orders are authorized. 11.0 PAYMENT TERMS AND INVOICING: The State of Wisconsin normally will pay properly submitted Contractor invoices within thirty(30)days of receipt providing goods and/or services have been delivered,installed(if required),and accepted as specified. Invoices presented for payment must be submitted in accordance with instructions contained on the purchase order including reference to purchase order number and submittal to the correct address for processing. A good faith dispute creates an exception to prompt payment. 12.0 TAXES: The State of Wisconsin and its agencies are exempt from payment of all federal tax and Wisconsin state and local taxes on its purchases except Wisconsin excise taxes as described below. The State of Wisconsin,including all its agencies,is required to pay the Wisconsin excise or occupation tax on its purchase of beer, liquor,wine, cigarettes, tobacco products,motor vehicle fuel and general aviation fuel. However,it is exempt from payment of Wisconsin sales or use tax on its purchases. The State of Wisconsin may be subject to other states'taxes on its purchases in that state depending on the laws of that state. Contractors performing construction activities are required to pay state use tax on the cost of materials. 13.0 GUARANTEED DELIVERY: Failure of the contractor to adhere to delivery schedules as specified or to promptly replace rejected materials shall render the contractor liable for all costs in excess of the contract price when alternate procurement is necessary. Excess costs shall include the administrative costs. 14.0 ENTIRE AGREEMENT: These Standard Terms and Conditions shall apply to any contract or order awarded as a result of this request except where special requirements are stated elsewhere in the request; in such cases, the special requirements shall apply. Further, the written contract and/or order with 21 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A • referenced parts and attachments shall constitute the entire agreement and no other terms and conditions in any document,acceptance,or acknowledgment shall be effective or binding unless expressly agreed to in writing by the contracting authority. 15.0 APPLICABLE LAW AND COMPLIANCE:This contract shall be governed under the laws of the State of Wisconsin. The contractor shall at all times comply with and observe all federal and state laws, local laws,ordinances,and regulations which are in effect during the period of this contract and which in any manner affect the work or its conduct. The State of Wisconsin reserves the right to cancel this contract if the contractor fails to follow the requirements of s.77.66,Wis. Stats.,and related statutes regarding certification for collection of sales and use tax. The State of Wisconsin also reserves the right to cancel this contract with any federally debarred contractor or a contractor that is presently identified on the list of parties excluded from federal procurement and non-procurement contracts. 16.0 ANTITRUST ASSIGNMENT:The contractor and the State of Wisconsin recognize that in actual economic practice,overcharges resulting from antitrust violations are in fact usually borne by the State of Wisconsin(purchaser). Therefore,the contractor hereby assigns to the State of Wisconsin any and all claims for such overcharges as to goods,materials or services purchased in connection with this contract. 17.0 ASSIGNMENT: No right or duty in whole or in part of the contractor under this contract may be assigned or delegated without the prior written consent of the State of Wisconsin. 18.0 WORK CENTER CRITERIA: A work center must be certified under s. 16.752,Wis.Stats., and must ensure that when engaged in the production of materials, supplies or equipment or the performance of contractual services,not less than seventy-five percent(75%)of the total hours of direct labor are performed by severely handicapped individuals. 19.0 NONDISCRIMINATION/AFFIRMATIVE ACTION: In connection with the performance of work under this contract, the contractor agrees not to discriminate against any employee or applicant for employment because of age,race,religion,color,handicap,sex,physical condition,developmental disability as defined in s.51.01(5),Wis.Stats., sexual orientation as defined in s. 111.32(13m),Wis.Stats.,or national origin. This provision shall include, but not be limited to,the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation;and selection for training,including apprenticeship. Except with respect to sexual orientation,the contractor further agrees to take affirmative action to ensure equal employment opportunities. 19.1 Contracts estimated to be over twenty-five thousand dollars($25,000)require the submission of a written affirmative action plan by the contractor. An exemption occurs from this requirement if the contractor has a workforce of less than twenty-five(25)employees. Within fifteen(15)working days after the contract is awarded, the contractor must submit the plan to the contracting state agency for approval. Instructions on preparing the plan and technical assistance regarding this clause are available from the contracting state agency. 19.2 The contractor agrees to post in conspicuous places,available for employees and applicants for employment,a notice to be provided by the contracting state agency that sets forth the provisions of the State of Wisconsin's nondiscrimination law. . 19.3 Failure to comply with the conditions of this clause may result in the contractor's becoming declared an "ineligible" contractor, termination of the contract,or withholding of payment. 20.0 PATENT INFRINGEMENT:The contractor selling to the State of Wisconsin the articles described herein guarantees the articles were manufactured or produced in accordance with applicable federal labor laws. Further,that the sale or use of the articles described herein will not infringe any United States patent. The contractor covenants that it will at its own expense defend every suit which shall be brought against the State of Wisconsin(provided that such contractor is promptly notified of such suit,and all papers therein are delivered to it)for any alleged infringement of any patent by reason of the sale or use of such articles, and agrees that it will pay all costs,damages,and profits recoverable in any such suit. 21.0 SAFETY REQUIREMENTS: All materials,equipment,and supplies provided to the State of Wisconsin must comply fully with all safety requirements as set forth by the Wisconsin Administrative Code and all applicable OSHA Standards. 22.0 WARRANTY:Unless otherwise specifically stated by the bidder/proposer,equipment purchased as a result of this request shall be warranted against defects by the bidder/proposer for one(1)year from date of receipt. The equipment manufacturer's standard warranty shall apply as a minimum and must be honored by the contractor. 23.0 INSURANCE RESPONSIBILITY: The contractor performing services for the State of Wisconsin shall: 23.1 Maintain worker's compensation insurance as required by Wisconsin Statutes,for all employees engaged in the work. 23.2 Maintain commercial liability,bodily injury and property damage insurance against any claim(s)which might occur in carrying out this agreement/contract. Minimum coverage shall be one million dollars($1,000,000) liability for bodily injury and property damage including products liability and completed operations. Provide motor vehicle insurance for all owned,non-owned and hired vehicles that are used in carrying out this contract. Minimum coverage shall be one million dollars($1,000,000)per occurrence combined single limit for automobile liability and property damage. 23.3 The state reserves the right to require higher or lower limits where warranted. 24.0 CANCELLATION: The State of Wisconsin reserves the right to cancel any contract in whole or in part without penalty due to no appropriation of funds or for failure of the contractor to comply with terms,conditions,and specifications of this contract. 25.0 CONTRACTOR TAX DELINQUENCY: Contractors who have a delinquent Wisconsin tax liability may have their payments offset by the State of Wisconsin. 26.0 PUBLIC RECORDS ACCESS: It is the intention of the state to maintain an open and public process in the solicitation, submission, review, and approval of procurement activities. 22 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A Bid/proposal openings are public unless otherwise specified. Records may not be available for public inspection prior to issuance of the notice of intent to award or the award of the contract. 27.0 PROPRIETARY INFORMATION: Any restrictions on the use of data contained within a request,must be clearly stated in the bid/proposal itself. Proprietary information submitted in response to a request will be handled in accordance with applicable State of Wisconsin procurement regulations and the Wisconsin public records law. Proprietary restrictions normally are not accepted. However, when accepted, it is the Contractor's responsibility to defend the determination in the event of an appeal or litigation. 27.1 Data contained in a bid/proposal,all documentation provided therein,and innovations developed as a result of the contracted commodities or services cannot be copyrighted or patented. All data,documentation,and innovations become the property of the State of Wisconsin. 27.2 Any material submitted by the Contractor in response to this request that the Contractor considers confidential and proprietary information and which qualifies as a trade secret,as provided in s.19.36(5),Wis.Stats.,or material which can be kept confidential under the Wisconsin public records law,must be identified on a Designation of Confidential and Proprietary Information form(DOA-3027). Bidders/proposers may request the form if it is not part of the Request for Bid/Request for Proposal package. Bid/proposal prices cannot be held confidential. 28.0 DISCLOSURE: If a state public official(s.19.42,Wis.Stats.),a member of a state public official's immediate family,or any organization in which a state public official or a member of the official's immediate family owns or controls a ten percent(10%)interest,is a party to this agreement,and if this agreement involves payment of more than three thousand dollars($3,000)within a twelve(12)month period,this contract is voidable by the state unless appropriate disclosure is made according to s.19.45(6),Wis.Stats.,before signing the contract. Disclosure must be made to the State of Wisconsin Ethics Board,44 East Mifflin Street, Suite 601,Madison,Wisconsin 53703(Telephone 608-266-8123). State classified and former employees and certain University of Wisconsin faculty/staff are subject to separate disclosure requirements,s.16.417,Wis.Stats. 29.0 RECYCLED MATERIALS: The State of Wisconsin is required to purchase products incorporating recycled materials whenever technically and economically feasible. Bidders are encouraged to bid products with recycled content which meet specifications. 30.0 MATERIAL SAFETY DATA SHEET: If any item(s)on an order(s)resulting from this award(s)is a hazardous chemical,as defined under 29CFR 1910.1200,provide one(1)copy of a Material Safety Data Sheet for each item with the shipped container(s)and one(1)copy with the invoice(s). 31.0 PROMOTIONAL ADVERTISING/NEWS RELEASES: Reference to or use of the State of Wisconsin,any of its departments,agencies or other subunits,or any state official or employee for commercial promotion is prohibited. News releases pertaining to this procurement shall not be made without prior approval of the State of Wisconsin. Release of broadcast e-mails pertaining to this procurement shall not be made without prior written authorization of the contracting agency. 32.0 HOLD HARMLESS: The contractor will indemnify and save harmless the State of Wisconsin and all of its officers,agents and employees from all suits,actions,or claims of any character brought for or on account of any injuries or damages received by any persons or property resulting from the operations of the contractor,or of any of its contractors,in prosecuting work under this agreement. 33.0 FOREIGN CORPORATION: A foreign corporation(any corporation other than a Wisconsin corporation)which becomes a party to this Agreement is required to conform to all the requirements of Chapter 180,Wis.Stats.,relating to a foreign corporation and must possess a certificate of authority from the Wisconsin Department of Financial Institutions, unless the corporation is transacting business in interstate commerce or is otherwise exempt from the requirement of obtaining a certificate of authority. Any foreign corporation which desires to apply for a certificate of authority should contact the Department of Financial Institutions,Division of Corporation,P.0.Box 7846,Madison,WI 53707-7846;telephone(608)261-7577. 34.0 WORK CENTER PROGRAM: The successful bidder/proposer shall agree to implement processes that allow the State agencies, including the University of Wisconsin System,to satisfy the State's obligation to purchase goods and services produced by work centers certified under the State Use Law,s.16.752,Wis. Stat. This shall result in requiring the successful bidder/proposer to include products provided by work centers in its catalog for State agencies and campuses or to block the sale of comparable items to State agencies and campuses. 35.0 FORCE MAJEURE: Neither party shall be in default by reason of any failure in performance of this Agreement in accordance with reasonable control and without fault or negligence on their part. Such causes may include, but are not restricted to,acts of nature or the public enemy,acts of the government in either its sovereign or contractual capacity,fires,floods,epidemics,quarantine restrictions, strikes,freight embargoes and unusually severe weather, but in every case the failure to perform such must be beyond the reasonable control and without the fault or negligence of the party. • 23 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A SUPPLEMENTAL STANDARD TERMS AND CONDITIONS FOR PROCUREMENT OF SERVICES,DOA-3681(R01/2001) 1.0 ACCEPTANCE OF BID/PROPOSAL CONTENT: The contents of the bid/proposal of the successful contractor will become contractual obligations if procurement action ensues. 2.0 CERTIFICATION OF INDEPENDENT PRICE DETERMINATION: By signing this bid/proposal,the bidder/proposer certifies, and in the case of a joint bid/proposal,each party thereto certifies as to its own organization,that in connection with this procurement: L1 The prices in this bid/proposal have been arrived at independently,without consultation, communication, or agreement,for the purpose of restricting competition,as to any matter relating to such prices with any other bidder/proposer or with any competitor; L2 Unless otherwise required by law, the prices which have been quoted in this bid/proposal have not been knowingly disclosed by the bidder/proposer and will not knowingly be disclosed by the bidder/proposer prior to opening in the case of an advertised procurement or prior to award in the case of a negotiated procurement,directly or indirectly to any other bidder/proposer or to any competitor;and !.3 No attempt has been made or will be made by the bidder/proposer to induce any other person or firm to submit or not to submit a bid/proposal for the purpose of restricting competition. L4 Each person signing this bid/proposal certifies that: He/she is the person in the bidder's/proposer's organization responsible within that organization for the decision as to the prices being offered herein and that he/she has not participated,and will not participate,in any action contrary to 2.1 through 2.3 above;(or) He/she is not the person in the bidder's/proposer's organization responsible within that organization for the decision as to the prices being offered herein, but that he/she has been authorized in writing to act as agent for the persons responsible for such decisions in certifying that such persons have not participated,and will not participate in any action contrary to 2.1 through 2.3 above,and as their agent does hereby so certify;and he/she has not participated,and will not participate,in any action contrary to 2.1 through 2.3 above. 3.0 DISCLOSURE OF INDEPENDENCE AND RELATIONSHIP: 3.1 Prior to award of any contract,a potential contractor shall certify in writing to the procuring agency that no relationship exists between the potential contractor and the procuring or contracting agency that interferes with fair competition or is a conflict of interest,and no relationship exists between the contractor and another person or organization that constitutes a conflict of interest with respect to a state contract. The Department of Administration may waive this provision, in writing, if those activities of the potential contractor will not be adverse to the interests of the state. 3.2 Contractors shall agree as part of the contract for services that during performance of the contract, the contractor will neither provide contractual services nor enter into any agreement to provide services to a person or organization that is regulated or funded by the contracting agency or has interests that are adverse to the contracting agency. The Department of Administration may waive this provision, in writing, if those activities of the contractor will not be adverse to the interests of the state. 4.0 DUAL EMPLOYMENT: Section 16.417, Wis. Stats., prohibits an individual who is a State of Wisconsin employee or who is retained as a contractor full-time by a State of Wisconsin agency from being retained as a contractor by the same or another State of Wisconsin agency where the individual receives more than $12,000 as compensation for the individual's services during the same year. This prohibition does not apply to individuals who have full-time appointments for less than twelve(12) months during any period of time that is not included in the appointment. It does not include corporations or partnerships. 5.0 EMPLOYMENT: The contractor will not engage the services of any person or persons now employed by the State of Wisconsin,including any department,commission or board thereof,to provide services relating to this agreement without the written consent of the employing agency of such person or persons and of the contracting agency. 6.0 CONFLICT OF INTEREST: Private and non-profit corporations are bound by ss. 180.0831, 180.1911(1), and 181.0831 Wis. Stets., regarding conflicts of interests by directors in the conduct of state contracts. 7.0 RECORDKEEPING AND RECORD RETENTION: The contractor shall establish and maintain adequate records of all expenditures incurred under the contract. All records must be kept in accordance with generally accepted accounting procedures. All procedures must be in accordance with federal,state and local ordinances. The contracting agency shall have the right to audit,review,examine,copy,and transcribe any pertinent records or documents relating to any contract resulting from this bid/proposal held by the contractor. The contractor will retain all documents applicable to the contract for a period of not less than three(3)years after final payment is made. 8.0 INDEPENDENT CAPACITY OF CONTRACTOR: The parties hereto agree that the contractor, its officers, agents, and employees, in the performance of this agreement shall act in the capacity of an independent contractor and not as an officer, employee, or agent of the state. The contractor agrees to take such steps as may be necessary to ensure that each subcontractor of the contractor will be deemed to be an independent contractor and will not be considered or permitted to be an agent,servant,joint venture,or partner of the state 24 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A CERTIFICATION REGARDING DEBARMENT AND SUSPENSION The undersigned (authorized official signing for the applicant organization) certifies to the best of his or her knowledge and belief that the applicant defined as the primary participant in accordance with 45 CFR Part 76, and its principles: (a) are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from covered transactions by any Federal department or agency; (b) have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offence in connection with obtaining, attempting to obtain or performing a public (Federal, State or local) transaction; violation of Federal or State antitrust statutes or commission of embezzlement,theft, forgery, bribery,falsification or destruction of records, making false statement or receiving stolen property; (c) are not presently indicated or otherwise criminally or civilly charged by a governmental entity(Federal, State or local)with commission of any of the offenses enumerated in paragraph (b) of this certification; and (d) have not within a three-year period preceding this application/proposal had one or more public transaction (Federal, State or local)terminated for cause or default. Should the applicant not be able to provide this certification, an explanation as to why should be placed after the assurances page. The applicant agrees that it will include, without modification,the clause titled 'Certification. Regarding Debarment, Suspension, In-eligibility, and Voluntary Exclusion-Lower Tier Covered Transaction'. (Appendix B to 45 CFR Part 76) in all lower tier covered transactions (i.e. transactions with sub grantees and/or contractors) and in all solicitations for lower tier covered transactions. EDocuSigned LtiV044.• 11/1/2011 E3E9BCA3ECOA 419 (Signature of Official Authorized to Sign Application) (Date) Denise Krueger RN, Interim Health Officer (Print Name) (Title) City of Oshkosh, Health Services (Agency/County Name) 25 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A CERTIFICATION REGARDING LOBBYING Certification for Contracts, Grants, Loans, and Cooperative Contracts The undersigned certifies,to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract,the making of any Federal grant,the making of any Federal loan, the entering into of any cooperative contract, and the extension, continuation, renewal, amendment, or modification of any Federal contract,grant, loan, or cooperative contract. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member.of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract,grant, loan, or cooperative contract,the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (3)The undersigned shall require that the language of this certification be included in the award documents for all sub awards at all tiers (including subcontracts, sub grants, and contracts under grants, loans and cooperative contracts) and that all sub recipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352,title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. • i—DocuSipned by. 11/1/2011 F3F9BCA3FCOA41 B (Signature of Official Authorized to Sign Application) (Date) Denise Krueger RN, Interim Health officer (Print Name) (Title) City of oshkosh, Health services Refugee Health Screening (Agency/County Name) (Title of Program) 26 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A _WISCONSIN DEPARTMENT OF CHILDREN AND FAMILIES DISCLOSURE OF LOBBYING ACTIVITIES Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352 (See reverse for public burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type: a. contract a. bid/offer/application a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. post award For Material Change Only: year quarter d. loan date of last report e. loan guarantee f. loan insurance 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is Sub awardee,Enter Name and Address of Prime: ? Prime ? Sub awardee Tier ,if known: Congressional District,if known: Congressional District,if known: 6. Federal Department/Agency: 7. Federal Program Name/Description: CFDA Number,if applicable: 8. Federal Action Number,if known: 9. Award Amount,if known: 27 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A WISCONSIN DEPARTMENT OF CHILDREN AND FAMILIES 11. Amount of Payment(check all that apply): 13. Type of Payment(check all that apply): $ ?actual ?planned ? a. retainer ? b. one-time fee ? c. commission ? d. contingent fee ? e. deferred ? f. other;specify: 12. Form of Payment(check all that apply): ? a. cash ? b. in-kind;specify: nature value 14. Brief Description of Services Performed or to be Performed and Date(s)of Service,including officer(s),employee(s),or Member(s)contacted,for Payment indicated in Item 11: 15. Continuation Sheet(s)SF-ILL-A attached: ?Yes ?No 16. Information requested through this form is authorized by title 31 U.S.C.section 1352.This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when this transaction was made or entered Into.This disclosure is required pursuant to 31 U.S.C.1352.This information will be reported to the Congress semi--annually and will be available for public inspection.Any Signature: person who falls to file the required disclosure shall be subject to a dvil penalty of not less than$10,000 and not more than$100,000 for each such failure. Print Name: Title: Tele. No: Date: 28 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A .WISCONSIN DEPARTMENT OF CHILDREN AND FAMILIES DISCLOSURE OF LOBBYING ACTIVITIES CONTINUATION SHEET Reporting Entity: Page of 29 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A .WISCONSIN DEPARTMENT OF CHILDREN AND FAMILIES INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES This disclosure form shall be completed by the reporting entity,whether sub awardee or prime Federal recipient,at the initiation or receipt of a covered Federal action,or a material change to a previous filing,pursuant to title 31 U.S.C.section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing or attempting to influence an officer or employee of any agency,a Member of Congress,an officer or employee of Congress,or an employee of a Member of Congress in connection with a covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information. 1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action. 2. Identify the status of the covered Federal action. 3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the information previously reported,enter the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal action. 4. Enter the full name,address,city,state and zip code of the reporting entity. Include Congressional District,if known. Check the appropriate classification of the reporting entity that designates if it is,or expects to be,a prime or sub award recipient. Identify the tier of the sub awardee,e.g.,the first sub awardee of the prime is the 1st tier. Sub awards include but are not limit to subcontracts,sub grants ad contract awards under grants. 5. If the organization filing the report in item 4 checks"Sub awardee",then enter the full name,address,city,state and zip code of the prime Federal recipient. Include Congressional District,if known. 6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name,if known. For example,Department of Transportation,United States Coast Guard. 7. Enter the Federal program name or description for the covered Federal action(item 1). If known,enter the full Catalog of Federal Domestic Assistance (CFDA)number for grants,cooperative agreements,loans,and loan commitments. 8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1(e.g.,Request for Proposal(RFP)number; Invitation for Bid(IFB)number;grant announcement number;the contract,grant,or loan award number;the application/proposal control number assigned by the Federal agency). Include prefixes,e.g.,"RFP-90-001." 9. For a covered Federal action where there has been an award or loan commitment by the Federal agency,enter the Federal amount of the award/loan commitment for the prime entity identified in item 4 or 5. 10. (a) Enter the full name,address,city,state and zip code of the lobbying entity engaged by the reporting entity identified in item 4 to influence the covered Federal action. (b) Enter the full names of the individual(s)performing services,and include full address if different from 10(a). Enter Last Name,First Name,and Middle Initial(MI). 11. Enter the amount of compensation paid or reasonable expected to be paid by the reporting entity(item 4)to the lobbying entity(item 10). Indicate whether the payment has been made(actual)or will be made(planned). Check all boxes that apply. If this is a material change report,enter the cumulative amount of payment made or planned to be made. 12. Check the appropriate box(es). Check all boxes that apply. If payment is made through an in-kind contribution,specify the nature and value of the in-kind payment. 13. Check the appropriate box(es). Check all boxes that apply. If other,specify nature. 14. Provide a specific and detailed description of the services that the lobbyist has performed,or will be expected to perform,and the date(s)of any services rendered. Include all preparatory and related activity,not just time spent in actual contact with Federal officials. Identify the Federal official(s)or employee(s)contacted or the officer(s),employee(s),or Member(s)of Congress that were contacted. 15. Check whether or not a SF-LLL-A Continuation Sheet(s)is attached. Public reporting burden for this collection of information is estimated to average 30 minutes per response,including time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden,to the Office of Management and Budget,Paperwork Reduction Project(0348-0046),Washington,D.C.20503. 16. The certifying official shall sign and date the form,print his/her name,title,and telephone number. 30 DocuSign Envelope ID: 16AB516B-F66B-4BCF-A068-85C8677A352A WISCONSIN DEPARTMENT OF CHILDREN AND FAMILIES CIVIL RIGHTS COMPLIANCE As a condition of funding under this contract,the Contractor provides the following assurances: (1) Services will be provided without discrimination in compliance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973,Title VI and XVI of the Public Health Service Act,the Age Discrimination Act of 1975,the Omnibus Budget Reconciliation Act of 1981, and the Americans with Disabilities Act(ADA)of 1990. No otherwise qualified person shall be excluded from participation in, be denied the benefits of, or otherwise be subject to discrimination in any manner on the basis of race, color, national origin, religion, sex, disability or age.This policy covers eligibility for and access to service delivery and treatment in all programs and activities. If special translation or sign language skilled staff is not available,The Contractor will provide staff with special translation or sign language skills training or will find persons who are available within a reasonable time and who can communicate with non-English speaking or hearing-impaired clients. Staff will receive training in sensitivity to persons with disabilities and sensitivity to cultural characteristics. Programs will be made accessible as appropriate in compliance with the ADA. Informational materials will be posted and/or available in languages and formats appropriate to the needs of the client population. (2) No otherwise qualified person shall be excluded from employment, be denied the benefits of employment or otherwise be subject to discrimination in employment in any manner or term of employment on the basis of age, race, religion, color, sex, national origin or ancestry, handicap (as defined in Section 504 and the ADA), physical condition, developmental disability(as defined ins. 51.05 (5), Wis. Stats.), arrest or conviction record (in keeping with s. 111.321, Wis. Stats.), sexual orientation, marital status or military participation. All employees are expected to support goals and programmatic activities relating to nondiscrimination in employment. (3) The Equal Opportunity Policy,the name of the Equal Opportunity Coordinator and the discrimination complaint process shall be posted in conspicuous places available to applicants and clients of services, and applicants for employment and employees. The complaint process will be according to Department of Children and Families' standards. (4) The Contractor agrees to comply with civil rights monitoring reviews including the examination of records and relevant files maintained by the agency, as well as interviews with staff, clients, applicants for services, subcontractors and referral agencies. (5) The Contractor agrees to cooperate with the Department in developing, implementing and monitoring corrective action plans that result from complaint investigations or other monitoring efforts. City of oshkosh, Health Services Division 5v/County Name) �rnioti `ern. 11/1/2011 (Signature of Official Authorized to Sign Application) (Date) Denise Krueger RN, Znterim Health officer (Print Name) (Title) 31 Docu,17:ort;.... Certificate of Completion Envelope Number: 16AB516BF66B4BCFA06885C8677A352A Status:Completed Subject:331 Refugee Health Screen Contract-City of Oshkosh Source Envelope: Document Pages:33 Signatures:4 Envelope Originator: Certificate Pages:5 Initials:0 DCF AutoNav:Enabled 201 E.Washintgon Ave.,Room A200 Envelopeld Stamping:Enabled PO Box 8916 Madison,WI 53708-8916 dcfcontracting @wi.gov IP Address: 165.189.32.4 Record Tracking Status:Original Holder:DCF Location:DocuSign 10/7/2011 4:49:25 AM PST dcfcontracting @wi.gov Signer Events Signature Timestamp Denise Krueger Docusigned by: Sent: 10/26/2011 12:59:04 PM PT dkrueger @ci.oshkosh.wi.us Resent: 11/1/2011 5:51:00 AM PT RN,Interim Health Officer e3e9ecn3econ41e... tI Delivered: 11/1/2011 7:17:23 AM PT City of Oshkosh,Health Services Signed: 11/1/2011 7:32:29 AM PT Security Level:Email,Account Authentication Using IP Address: 199.248.186.5 (None) Consumer Disclosure: • Accepted: 11/1/2011 7:17:23 AM ID:855c98d1-4d0f-44fe-a13a-1842da392785 In Person Signer Events Signature Timestamp' Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Jayne Tebon COPIED Sent: 10/26/2011 12:59:06 PM PT jtebon @ci.oshkosh.wi.us J�L Security Level:Email,Account Authentication (None) Consumer Disclosure: Accepted: 10/11/2011 9:04:01 AM ID:59ddc06c-0633-4ef7-9a14-89ac74de98c2 Irina Ertl ��� Sent: 11/1/2011 7:32:32 AM PT Irina.Ertl©wisconsin.gov Security Level: Email,Account Authentication (None) Consumer Disclosure: Accepted: 10/11/2011 8:49:57 AM ID:bdab30f3-54d9-40a9-bed4-214ada450730 Lucinda Champion �� Sent: 11/1/2011 7:32:32 AM PT lucinda.champion @wi.gov Security Level:Email,Account Authentication (None) Carbon Copy Events Status Timestamp Consumer Disclosure: Accepted:9/30/2011 5:31:14 AM ID:3b275ae9-b04e-454a-a635-4e3165e9ee7a Mette Brogden COPIED Sent: 11/1/2011 7:32:32 AM PT Mette.Brogden @wisconsin.gov Security Level:Email,Account Authentication (None) Consumer Disclosure: Accepted: 10/7/2011 9:12:12 AM ID:4d4d40d9-4449-4aa2-9c84-273e4b1f50c6 Verna Ruhs �� Sent: 11/1/2011 7:32:32 AM PT verna.ruhs @wi.gov Security Level: Email,Account Authentication (None) Consumer Disclosure: Accepted: 10/14/2011 6:47:57 AM ID:da7c6cde-ebe7-444c-8bc9-1a2d4aa700f4 Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 11/1/2011 7:32:32 AM PT Certified Delivered Security Checked 11/1/2011 7:32:32 AM PT Signing Complete Security Checked 11/1/2011 7:32:32 AM PT Completed Security Checked 11/1/2011 7:32:32 AM PT Consumer Disclosure Consumer Disclosure created on:3/16/2011 9:37:25 AM Parties agreed to:Denise Krueger,Jayne Tebon,Irina Ertl,Lucinda Champion,Mette Brogden,Verna Ruhs CONSUMER DISCLOSURE From time to time, State of WI(we, us or Company) may be required by law to provide to you certain written notices or disclosures. 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Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from us. How to contact State of WI: You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows: To contact us by email send messages to: dcfcontracting @wisconsin.gov To advise State of WI of your new e-mail address To let us know of a change in your e-mail address where we should send notices and disclosures electronically to you,you must send an email message to us at dcfcontracting @wisconsin.gov and in the body of such request you must state: your previous e-mail address, your new e-mail address. We do not require any other information from you to change your email address.. 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To withdraw your consent with State of WI To inform us that you no longer want to receive future notices and disclosures in electronic format you may: i. decline to sign a document from within your DocuSign session, and on the subsequent page, select the check-box indicating you wish to withdraw your consent, or you may; ii. send us an e-mail to dcfcontracting @wisconsin.gov and in the body of such request you must state your e-mail, full name, US Postal Address, and telephone number. We do not need any other information from you to withdraw consent.. The consequences of your withdrawing consent for online documents will be that transactions may take a longer time to process.. 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Acknowledging your access and consent to receive materials electronically To confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you,please verify that you were able to read this electronic disclosure and that you also were able to print on paper or electronically save this page for your future reference and access or that you were able to e-mail this disclosure and consent to an address where you will be able to print on paper or save it for your future reference and access. Further, if you consent to receiving notices and disclosures exclusively in electronic format on the terms and conditions described above,please let us know by clicking the a€I agreea€TM button below. By checking the a€°T agreed€TM box, I confirm that: • I can access and read this Electronic CONSENT TO ELECTRONIC RECEIPT OF ELECTRONIC CONSUMER DISCLOSURES document; and • I can print on paper the disclosure or save or send the disclosure to a place where I can print it, for future reference and access; and • Until or unless I notify State of WI as described above, I consent to receive from exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to me by State of WI during the course of my relationship with you.