HomeMy WebLinkAboutPD15-145 - Original - WA State Department of Social and Health Services - Let's Draw the Line Campaign - 03/17/2015 i
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W.. roN Document
K HINGTON
CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to City Clerks Office. All portions are to be completed.
If you have questions, please contact City Clerk's Office.
Vendor Name: WA State Department of Social and Health Services
Vendor Number: 41278
7D Edwards Number
Contract Number: l�u
This is assigned by City Clerk's Office
Project Name: Let's Draw The Line Campaign
Description: X Interlocal Agreement ❑ Change Order ❑ Amendment Contract
❑ Other:
Contract Effective Date: 3/17/2015 Termination Date: 6/30/2015
Contract Renewal Notice (Days): N/A
Number of days required notice for termination or renewal or amendment
Contract Manager: Sara Wood Department: Police
Contract Amount: $1,000
Approval Authority: (CIRCLE ONE) Department Director Mayor City Council
Detail: (i.e. address, location, parcel number, tax id, etc.):
This interlocal agreement will provide funding for participation by the Kent Police
Department in the statewide "Let's Draw the Line"campaign sponsored by Washington
State Department of Social and Health Services.
.-._. . .-.--... ..
As of; 08/27/14
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INTERLOCAL AGREEMENT OS}IS Agreement Number.
�;�,,,,,pp„ swee 1564-35506
67F
8ER ACEST�
Let's Draw the Line
This Agreement is by and between the State of Washington Department Program Contract Number:
of Social and Health Services(DSHS)and the Contractor identifled Contractor Contract Number:
below, and is issued pursuant to the Interloc,�l Cooperation Act, chapter
39.34 RCW,
CONTRACTOR NAME CONTRACTOR doing business as(DBA)
City of Kent
? CONTRACTOR ADDRESS WASHINGTON UNIFORM DSHS INDEX NUMBER
BUSINESS IDENTIFIER(UBI)
220 4th Ave South
Kent IA 98D32-5895 173-000-002 22475
CONTRACTOR CONTACT CONTRACTOR TELEPHONE CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESS
Ken Thomas 253 856-5863 1 (253)856-6802 kthomas(ftentwo.c
Iov
DSHS ADMINISTRATION DSHS DIVISION DSHS CONTRACT CODE
Behavioral Health and Service Division of Behavioral Health and Recovery 10001-C-64
Inte ration
DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS
Beatriz Mendez PO Box45625
prevention Services Lead _ Olympia,WA 98504
DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS
360 725-9984 Beatriz.mendez dshs.wa.gov
1S THE CONTRACTOR A SUBRECIPIEN I FOR PURPOSES OF THIS CONTRACT? CFDA NUMBER(S)
No 16.727
AGREEMENT START DATE FAIG3,IRFE—MENT END DATE MAXIMUM AGREEMENTFlPAOVNT
03/17/2015 30/2015 $1.000.00
EXHIBITS. The following Exhibits are attached and are incorporated into this Agreement by reference:
®Exhibits(specify): No Data Security Exhibit Exhibit A: Agency Registration and Application Form
No Exhibits.
The tefrths and con l_itlgns df this ,greement a(e al}pltegTatlon and,represohtetiott of the flhal, enfife aV exclusive
tlhd�Dsf ndrng between the parties superseding an�Merging al i previous agreements writings an communications brat
or oche vise rasarding rlhe subject m8lter of jhls bgreemuttt between the parties,;Thepa Pies signing Below fepresent
the av'e ea'd and f der�lld t�I§Agreement,and h ve the 66166rity(o execute this Agreement: This Agreement shell
t r
be df D$FfS onf 't on$i nature by
CO RAC SIGNATURE PRINTED NAMEANDTITLE DATESIGNED
4nn bLvd-15 urn elF 0 tilil t S
DSH IGN URE PRINTED qME A p TITLE, DATE SIGNED
DSHS Central Contract Services
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DSHS General Terms and Conditions
1. Definitions. The words and phrases listed below, as used in this Contract, shall each have the
following definitions:
a. "Central Contract Services" means the DSHS central headquarters contracting office, or successor
section or office,
b. "Confidential Information" or"Data" means information that is exempt from disclosure to the public
or other unauthorized persons under RCW 42.56 or other federal or state laws. Confidential
Information includes, but is not limited to, Personal Information.
c. "Contract" or"Agreement" means the entire written agreement between DSHS and the Contractor,
including any Exhibits, documents, or materials incorporated by reference.The parties may execute
this contract in multiple counterparts, each of which is deemed an original and all of which
constitute only one agreement. E-mail or Facsimile transmission of a signed copy of this contract
shall be the same as delivery of an original.
d. "Contracts Administrator" means the manager, or successor, of Central Contract Services or
successor section or office.
e. "Contractor" means the individual or entity performing services pursuant to this Contract and
includes the Contractor's owners, members, officers, directors, partners, employees, and/or agents,
unless otherwise stated in this Contract. For purposes of any permitted Subcontract, "Contractor"
includes any Subcontractor and its owners, members,.officers, directors, partners, employees,
and/or agents.
f. "Debarment" means an action taken by a Federal agency or official to exclude a person or business
entity from participating in transactions involving certain federal funds.
g, "DSHS" or the "Department" means the state of Washington Department of Social and Health
Services and its employees and authorized agents.
h. "Encrypt" means to encode Confidential Information into a format that can only be read by those
possessing a "key"; a password, digital certificate or other mechanism available only to authorized
users. Encryption must use a key length of at least 128 bits.
I. "Personal Information" means information identifiable to any person, including, but not limited to,
information that relates to a person's name, health, finances, education, business, use or receipt of
governmental services or other activities, addresses, telephone numbers, Social Security Numbers,
driver license numbers, other identifying numbers, and any financial identifiers.
j. "Physically Secure" means that access is restricted through physical means to authorized
individuals only.
k. "Program Agreement" means an agreement between the Contractor and DSHS containing special
terms and conditions, including a statement of work to be performed by the Contractor and payment
to be made by DSHS.
1. 'RCW" means the Revised Code of Washington. All references in this Contract to RCW chapters or
sections shall include any successor, amended, or replacement statute. Pertinent RCW chapters
can be accessed at http://apps.leg.wa,govlrcw/.
m. "Regulation" means any federal, state, or local regulation, rule, or ordinance.
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DSHS General Terms and Conditions
n. "Secured Area" means an area to which only authorized representatives of the entity possessing
the Confidential Information have access. Secured Areas may include buildings, rooms or locked
storage containers (such as a filing cabinet)within a room, as long as access to the Confidential
Information is not available to unauthorized personnel.
o. "Subcontract" means any separate agreement or contract between the Contractor and an individual
or entity ("Subcontractor") to perform all or a portion of the duties and obligations that the Contractor
is obligated to perform pursuant to this Contract.
p. "Tracking" means a record keeping system that identifies when the sender begins delivery of
Confidential Information to the authorized and intended recipient, and when the sender receives
confirmation of delivery from the authorized and intended recipient of Confidential Information.
q. "Trusted Systems" include only the following methods of physical delivery: (1) hand-delivery by a .
person authorized to have access to the Confidential Information with written acknowledgement of
receipt; (2) United States Postal Service ("USPS") first class mail, or USPS delivery services that
include Tracking, such as Certified Mail, Express Mail or Registered Mail; (3) commercial delivery
services (e.g. FedEx, UPS, DHL) which offer tracking and receipt confirmation; and (4) the
Washington State Campus mail system. For electronic.transmission, the Washington State
Governmental Network (SGN) is a Trusted System for communications within that Network.
r. "WAC" means the Washington Administrative Code. All references in this Contract to WAC
chapters or sections shall include any successor, amended,.or replacement regulation. Pertinent
WAC chapters or sections can be accessed at http://apps.leg.wa.gov/wac/.
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2. Amendment. This Contract may only be modified by a written amendment signed by both parties. Oniy
personnel authorized to bind each of the parties may sign an amendment.
3. Assignment. The Contractor shall not assign this Contract or any Program Agreement to a third party
without the prior written consent of DSHS.
4. Billing Limitations.
a. DSHS shall pay the Contractor only for authorized services provided in accordance with this
Contract.
b. DSHS shall not pay any claims for payment for services submitted more than twelve (12) months
after the calendar month in which the services were performed.
c. The Contractor shall not bill and DSHS shall not pay for services performed under this Contract, if
the Contractor has charged or will charge another agency of the state of Washington or any other
party for the same services.
5. Compliance with Applicable Law. At all times during the term of this Contract, the Contractor shall
comply with all applicable federal, state, and local laws and regulations, including but not limited to,
nondiscrimination laws and regulations.
6. Confidentiality.
a. The Contractor shall not use, publish, transfer, sell or otherwise disclose any Confidential
Information gained by reason of this Contract for any purpose that is not directly connected with
Contractor's performance of the services contemplated hereunder, except:
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(1) as provided by law; or,
(2) in the case of Personal Information, with the prior written consent of the person or personal
representative of the person who is the subject of the Personal Information. .
b. The Contractor shall protect and maintain all Confidential Information gained by reason of this
Contract against unauthorized use, access, disclosure, modification or loss. This duty requires the
Contractor to employ reasonable security measures, which include restricting access to the
Confidential Information by:
(1) Allowing access only to staff that have an authorized business requirement to view the
Confidential Information.
(2) Physically Securing any computers, documents, or othet media containing the Confidential
Information.
(3) Ensure the security of Confidential Information transmitted.via fax (facsimile) by:
(a) Verifying the recipient phone number to prevent accidental transmittal of Confidential
Information to unauthorized persons,
(b) Communicating with the intended recipient before transmission to ensure that the fax will be
received only by an authorized person.
(c) Verifying after transmittal that the fax was received by the intended recipient.
(4) When transporting six (6) or more records containing Confidential Information, outside a
Secured Area, do one or more of the following as appropriate:
(a) Use a Trusted System.
(b) Encrypt the Confidential Information, including:
I. Encrypting email and/or email attachments which contain the Confidential Information.
ii. Encrypting Confidential information when it is stored on portable devices or media,
including but not limited to laptop computers and flash memory devices.
Note: If the DSHS Data Security Requirements Exhibit is attached to this contract, this
item, &b.(4), is superseded by the language contained in the Exhibit.
(5) Send paper documents containing Confidential Information via 'a Trusted System.
(6) Following the requirements of the DSHS Data Security Requirements Exhibit, if attached to this
contract.
c. Upon request by DSHS, at the end of the Contract term, or when no longer needed, Confidential
Information shall be returned to.DSHS or Contractor shall certify in writing that they employed a
DSHS approved method to destroy the information. Contractor may obtain information regarding
approved destruction methods from the DSHS contact identified on the cover page of this Contract.
d. Paper documents with Confidential Information may be recycled through a contracted firm, provided
the contract with the recycler specifies that the confidentiality of information will be protected, and
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DSHS General Terms and Conditions
the information destroyed through the recycling process. Paper documents containing Confidential
Information requiring special handling (e.g. protected health information) must be destroyed on-site
through shredding, pulping, or incineration.
e. Notification of Compromise or Potential Compromise, The compromise or potential compromise of
Confidential Information must be reported to the DSHS Contact designated on the contract within
one (1) business day of discovery. Contractor must also take actions to mitigate the risk of loss and
comply with any notification or other requirements imposed by law or DSHS.
7. Debarment Certification. The Contractor, by signature to this Contract, certifies that the Contractor is
not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
by any Federal department or agency from participating in transactions (Debarred), The Contractor also
agrees to include the above requirement in any and all Subcontracts into which it enters. The
Contractor shall immediately notify DSHS if, during the term of this Contract, Contractor becomes
Debarred. DSHS may immediately terminate this Contract by providing Contractor written notice if
Contractor becomes Debarred during the term hereof.
8. Governing Law and Venue.This Contract shall be construed and interpreted in accordance with the
laws of the state of Washington and the venue of any action brought hereunder shall be in Superior
Court for Thurston County.
9. Independent Contractor. The parties intend that an independent contractor relationship will be created
by this Contract. The Contractor and his or her employees or agents performing under this Contract are
not employees or agents of the Department. The Contractor, his or her employees, or agents
performing under this Contract will not hold himself/herself out as, nor claim to be, an officer or
employee of the Department by reason hereof, nor will the Contractor, his or her employees, or agent
make any claim of right, privilege or benefit that would accrue to such officer or employee.
10. Inspection.The Contractor shall, at no cost, provide DSHS and the Office of the State Auditor with
reasonable access to Contractor's place of business, Contractor's records, and DSHS client records,
wherever located. These inspection rights are intended to allow DSHS and the Office of the State
Auditor to monitor, audit, and evaluate the Contractor's performance and compliance with applicable
laws, regulations, and these Contract terms. These inspection rights shall survive for six (6) years
following this Contract's termination or expiration.
11. Maintenance of Records. The Contractor shall maintain records relating to this Contract and the
performance of the services described herein. The records include, but are not limited to, accounting
procedures and practices, which sufficiently and properly reflect all direct and indirect costs of any
nature expended in the performance of this Contract. All records and other material relevant to this
Contract shall be retained for six (6) years after expiration or termination of this Contract.
Without agreeing that litigation or claims are legally authorized, if any litigation, claim, or audit is started
before the expiration of the six (6) year period, the records shall be retained until all litigation, claims, or
audit findings involving the records have been resolved.
12. Order of Precedence. In the event of any inconsistency or conflict between the General Terms and
Conditions and the Special Terms and Conditions of this Contract or any Program Agreement, the
inconsistency or conflict shall be resolved by giving precedence to these General Terms and
Conditions. Terms or conditions that are more restrictive, specific, or particular than those contained in
the General Terms and Conditions shall not be construed as being inconsistent or in conflict.
13. Severability. If any term or condition of this Contract is held invalid by any court, the remainder of the
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Contract remains valid and in full force and effect.
14. Survivability. The terms and conditions contained in this Contract or any Program Agreement which,
by their sense and context, are intended to survive the expiration or termination of the particular
agreement shall survive. Surviving terms include, but are not limited to: Billing Limitations;
Confidentiality, Disputes; Indemnification and Hold Harmless, Inspection, Maintenance of Records,
Notice of Overpayment, Ownership of Material, Termination for Default, Termination Procedure, and
Treatment of Property.
15. Contract Renegotiation, Suspension, or Termination Due to Change in Funding.
If the funds DSHS relied upon to establish this Contract or Program Agreement are withdrawn, reduced
or limited, or if additional or modified conditions are placed on such funding, after the effective date of
this contract but prior to the normal completion of this Contract or Program Agreement
a. At DSHS's discretion, the Contract or Program Agreement may be renegotiated under the revised
funding conditions.
b. DSHS's discretion, DSHS may give notice to Contractor to suspend performance when DSHS
determines that.there is reasonable likelihood that the funding insufficiency may be resolved in a
timeframe that would allow Contractor's performance to be resumed prior to the normal completion
date of this contract.
(1) During the period of suspension of performance, each party will inform the other of any
conditions that may reasonably affect the potential for resumption of performance.
(2) When DSHS determines that the funding insufficiency is resolved, it will give Contractor written
notice to resume performance. Upon the receipt of this notice, Contractor will provide written
notice to DSHS informing DSHS whether it can resume performance and, if so, the date of
resumption. For purposes of this subsubsection, "written notice" may include email.
(3) If the Contractor's proposed resumption date is not acceptable to DSHS and an acceptable date
cannot be negotiated, DSHS may terminate the contract by giving written notice to Contractor.
The parties agree that the Contract will be terminated retroactive to the date of the notice of
suspension. DSHS shall be liable only for payment in accordance with the terms of this
Contract for services rendered prior to the retroactive date of termination.
C. DSHS may immediately terminate this Contract by providing written notice to the Contractor. The
termination shall be effective on the date specified in the termination notice. DSHS shall be liable
only for payment in accordance with the terms of this Contract for services rendered prior to the
effective date of termination. No penalty shall accrue to.DSHS in the event the termination option in
this section is exercised.
15. Waiver.Waiver of any breach or default on any occasion shall not be deemed to be a waiver of any
subsequent breach or default. Any waiver shall not be construed to be a modification of the terms and
conditions of this Contract. Only the DSHS Contracts Administrator or designee has the authority to
waive any term or condition of this Contract on behalf of DSHS.
Additional General Terms and Conditions—Interlocal Agreements:
17. Disputes. Disputes shall be determined by a Dispute Board. Each party to this Agreement shall
appoint one member to the Dispute Board. The members so appointed shall jointly appoint an
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additional member to the Dispute Board. The Dispute Board shall review the facts, Agreement terms,
and applicable statutes and rules and make.a determination of the dispute. As an alternative to this
process, either party may request intervention by the Governor, as provided by RCW 43.17.330, in
which event the Governor's process shall control. Participation in either dispute process shall precede
any judicial or quasi-judicial action and shall be the final administrative remedy available to the parties.
18. Hold Harmless.
a. The Contractor shall be responsible for and shall hold DSHS harmless from all claims, loss, liability,
damages, or fines arising out of or relating to the Contractor's, or any Subcontractor's, performance
or failure to perform this Agreement, or the acts or omissions of the Contractor or any
Subcontractor. DSHS shall be responsible for and shall hold the Contractor harmless from all
claims, loss, liability, damages, or fines arising out of or relating to DSHS' performance or failure to
perform this Agreement.
b. The Contractor waives its immunity under Title 51 ROW to the extent it is required to indemnify,
defend, and hold harmless the State and its agencies, officials, agents, or employees.
19. Ownership of Material. Material created by the Contractor and paid for by DSHS as a part of this
Contract shall be owned by DSHS and shall be "work made for hire" as defined by Title 17 USCA,
Section 101. This material includes, but is not limited to: books; computer programs; documents; films;
pamphlets; reports; sound reproductions; studies; surveys; tapes; and/or training materials. Material
which the Contractor uses to perform the Contract but is not created for or paid for by DSHS is owned
by the Contractor and is not "work made for hire"; however, DSHS shall have a perpetual license to use
this material for DSHS internal purposes at no charge to DSHS, provided that such license shall be
limited to the extent which the Contractor has a right to grant such a license.
20. Subrecipients.
a. General. If the Contractor is a subrecipient of federal awards as defined by 2 CFR Part 200 and
this Agreement, the Contractor shall:
(1) Maintain records that identify, in its accounts, all federal awards received and expended and the
federal programs under which they were received, by Catalog of Federal Domestic Assistance
(CFDA) title and number, award number and year, name of the federal agency, and name of the
pass-through entity;
(2) Maintain internal controls that provide reasonable assurance that the Contractor is managing
federal awards in compliance with laws, regulations, and provisions of contracts or grant
agreements that could have a material effect on each of its federal programs;
(3) Prepare appropriate financial statements, including a schedule of expenditures of federal
awards;
(4) Incorporate 2 CFR Part 200, Subpart F audit requirements into all agreements between the
Contractor and its Subcontractors who are Subrecipients;
(5) Comply with the applicable requirements of 2 CFR Part 200, including any future amendments to
2 CFR Part 200, and any successor or replacement Office of Management and Budget(OMB)
Circular or regulation; and
(6) Comply with the Omnibus Crime Control and Safe streets Act of 1968, Title VI of the Civil Rights
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Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title II of the Americans with
Disabilities Act of 1990, Title IX of the Education Amendments of 1972, The Age Discrimination
Act of 1975, and The Department of Justice Non-Discrimination Regulations, 28 C.F.R. Part 42,
Subparts C.D.E. and G, and 28 C.F.R. Part 35 and 39. (Go to www,oip.usdoi.pov/ocr/for
additional information and access to the aforementioned Federal laws and regulations.)
b. Single Audit Act Compliance. If the Contractor is a subrecipient and expends $750,000 or more in
federal awards from any and/or all sources in any fiscal year, the Contractor shall procure and pay
for a single audit or a program-specific audit for that fiscal year. Upon completion of each audit, the
Contractor shall:
(1) Submit to the DSHS contact person the data collection form and reporting package specified in
2 CFR Part 200, Subpart F, reports required by the program-specific audit guide (if applicable),
and a copy of any management letters issued by the auditor;
(2) Follow-up and develop corrective action for all audit findings; in accordance with 2 CFR Part
200, Subpart F; prepare a "Summary Schedule of Prior Audit Findings" reporting the status of all
audit findings included in the prior audit's schedule of findings and questioned costs.
c. Overpayments. If it is determined by DSHS, or during the course of a required audit, that the
Contractor has been paid unallowable costs under this or any Program Agreement, DSHS may
require the Contractor to reimburse DSHS in accordance with 2 CFR Part 200.
21. Termination.
a. Default. If for any cause, either party fails to fulfill its obligations under this Agreement in a timely
and proper manner, or if either party violates any of the terms and conditions contained in this
Agreement, then the aggrieved party will give the other party written notice of such failure or
violation. The responsible party will be given 15 working days to correct the violation or failure. If
the failure or violation is not corrected, this Agreement may be terminated immediately by written
notice from the aggrieved party to the other party.
b. Convenience. Either party may terminate this Interlocal Agreement for any other reason by
providing 30 calendar days' written notice to the other party.
c. Payment for Performance. If this Interlocal Agreement is terminated for any reason, DSHS shall
only pay for performance rendered or costs incurred in accordance with the terms of this Agreement
and prior to the effective date of termination.
22. Treatment of Client Property. Unless otherwise provided, the Contractor shall ensure that any adult
client receiving services from the Contractor has unrestricted access to the client's personal property.
The Contractor shall not interfere with any adult client's ownership, possession, or use of the client's
property. The Contractor shall provide clients under age eighteen (18) with reasonable access to their
personal property that is appropriate to the client's age, development, and needs. Upon termination of
the Contract, the Contractor shall immediately release to the client and/or the client's guardian or
custodian all of the client's personal property.
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Special Terms and Conditions
1. Purpose. The purpose of this Contract is to support community norms, policies and
enforcement efforts that help prevent underage drinking by completing the Let's Draw the Line
(LDTL) Project activities indicated in the Statement of Work.
2. Statement of Work. The Contractor shall provide the services and staff, and otherwise do all
things necessary for or incidental to the performance of work, as described in Exhibit A:
Agency Registration and Application Form.
3. Performance Work Statement.
a. All reporting for the three (3) LDTL activities must be submitted together, in a final report,
on or before June 15, 2015, unless other arrangements are made with DBHR prior to this
deadline. The final report shall be submitted to: LDTL(a dshs.wa.gov
b. Payment Penalties: For each business day the final report is late, or incomplete, there will
be a $100 deduction, up to a maximum of$500.
4. Modifications. In the event the Contractor'encounters circumstances that may hinder their
ability to complete the agreed upon activities, the Contractor may request modifications.
Requests shall be made to the DSHS Contact as soon as possible. Determinations shall be
made on a case-by-case basis and the final decision shall rest solely with the DSHS Contact.
5. Consideration. Total consideration payable to Contractor for satisfactory performance of the
work under this Contract for Year 1 is up to a maximum of$1,000 including any and all
expenses, and shall be based on the Performance Work Statement. The source of funds is
the Office of Juvenile Justice & Delinquency Prevention's Enforcing Underage Drinking Laws
Grant#2011-AH-FX-0059, CFDA#16.727.
6. Billing and Payment.
a. Invoice System, The Contractor shall submit an invoice using State Form A-19 Invoice
Voucher, or such other form as designated by DSHS. Consideration for services rendered
shall be payable upon receipt of a properly completed invoice which shall be submitted to
the DSHS Contact, The invoices shall describe and document to DSHS' satisfaction a
description of the work performed and the activities accomplished. The rates shall be in
accordance with those set forth in Section 3, Performance Work Statement and Section 5,
Consideration, of this Contract.
b. Payment. Payment shall be considered timely if made by DSHS within thirty (30) days after
receipt and approval by the DSHS Contact of the properly completed invoice. Payment
shall be sent to the address designated by the Contractor on page one (1) of this Contract.
DSHS may, at its sole discretion, withhold payment claimed by the Contractor for services
rendered if Contractor fails to satisfactorily comply with any term or condition of this
Contract.
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Special Terms and Conditions
Exhibit A: Agency Registration and Application Form
Project contact person Stacyludd Phone number: 253-856.5883
Email address: sjudd@lcentwa.gov
Name of group that will carry out LDTL activities: Mailing address (including city and zip code): Kent
Kent Police Youth Board - Police Department,220 0 Ave S.,
County in which LDTL activities will occur: King Kent,WA 98032
Did you group participate in LDTL in 2014
XO Yes ❑ No
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ro(r cart,�C4'ntraa'�wi$iS�SFJ��i(�u�a�311j,�1Qecj�to�t3entifya`fiscalagt�haGDSHS-ca��contfaLfiNith��.-�
Name of fiscal agent/contractor organization: City of Kent Police Department
Name of fiscal agent/contractor contact person Chief Kent Thomas
Mailing address of fiscal agent(including city and 9-digit zip code): 220 a Ave S. Kent,WA 98032
Name of the person who will be implement this project:Stacy Judd
Contact information 253-856-5883;sjudd@kentwa.gov
Fiscal agent's EIN (9-digit Employer Identification Number): 91-6001254
Fiscal agent's DUNS: 0202536130000
Commitment: • Each group needs to do 3 activities total—the two required activities and one activity from a
list of options. Required reporting for each activity is listed next to each activity.
Funding: • Groups will receive$1,000 for completing all of their LDTL activities and for submitting
completed project reports in a timely manner.
There will be anew contract or amendment to exciting contracts, depending on local needs.
Project Period & • Complete Application for Contract Forms are due by February.14, 2015. If the application Is
Important Dates: accepted, you will be sent information needed to complete a contract.
• Applications are on a first come, first served basis.
Work on projects can begin as soon as a contract is in place.
• All activities must be completed by May 31, 2015, Short extensions may be possible on a case
by case basis if arrangements are made with DBHR prior to this deadline.
• All reporting and A-19 billing must be submitted by June 14, 2015, unless other arrangements
are made with DBHR prior to this deadline.
• Billings received after June 30, 2015 will not be paid.
• We need to have all documentation submitted before we can process a billing for payment.
DSHS Central Contract Servlces
6015LF Custom lnterlocal Agreement(6-30-09) Page 10
Special Terms and Conditions
Required Activities:
Community Assessment of Neighborhood Stores (CANS) surveys.
1. Give advance notice to retailers of your plan to conduct CANS.
2. Reach out to and build a rapport with retailers prior to conducting CANS.
• You must conduct 10 full CANS surveys in stores andsubmit to DSNR.
• For groups that don't have 10 stores, you need to go to nearby towns and communities to complete 10 full
CANS in stores and submit to DBHR..
• If you simply don't have 10 stores available, you must conduct full CANS survey in the stores you do have
and an exterior assessment in other establishments that sell alcohol that will add up to 10 and submit to
DBHR.
3, If you don't qualify with options 1, 2, or 3, please call Beatriz Mendez at 360-725-9984 to look at other
options. For returning groups, please re-surrey stores from last year.
4, . Summarize the results of your local CANS.
• Issue a press release announcing the results of your CANS. (Template to be provided.) Target for the
release is the week of May 18-24 (SAMHSA's National Prevention Week).
• Create a presentation summarizing the results of the local CANS. Present to at least one other organization
in your community.
Above the Influence Protect - Use the following "Above the Influence"campaign link
htip://www.atioartnerships,co m/to download the ATI Activities and choose one of the
projects listed below. You will need to create an account to he able to download the ATi activities.
1. "TAG IT" - Asks teens to tag the influences in their lives and share them with the world. This activity
increases teen's awareness of influences in their environment and how influences may encourage
there to matte eitherpositive or negative decisions.
2. "BE IT" —Asks teens to create their own personal slogan. This activity helps teens gain
understanding of brand value and how maintaining a brand's reputation affects the influence of the
brand.
3. "EXPRESS IT" -Asks teens to create a short skit, song or dance that educates and inspires them
and their peers to live Above the Influence."This will help teens gain an awareness of their influences
and issues impacting youth in their community.
4. "PICTURE IT" — Engages teens in a discussion and photo-sharing exercise that highlights the
potential pressures and risks they may face during their prom and graduation season.
5. "BRING IT" —Asks teens to "role play"a variety of scenarios that portray real and challenging
situations they might face in their daily lives.
6. D.DRIVER— Puts teens in the driver's seat by using video games and real-life scenarios to help them
gain a better understanding of the potential consequences of driving after using alcohol and other
drugs or while distracted.
7. INFLUENCE DISCUSSION—Engage teens in your school or community in a discussion about
"influence."The activity challenges youth to think critically about the adverse effects of drugs use and
the possible negative influences surrounding them in their social and media environment.
8. TEEN EXPRESSIONS ART PROJECT—Asks teens in your community to create their own visual
expressions of the Above the influence symbol.
Reporting - For Community Prevention and Wellness Initiative Communities (only); each of the required
LDTL activities will be entered into the Performance Base Prevention System (PBPS) under a single service
report.
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6015t-F Custom Interlocal Agreement(6-30-09) Page 11
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Special Terms and Conditions
Optional Activities — Choose one activity that best matches the needs of your
community.
Description of optional Activities: (glaE Reporting Requirement:
Media Awareness Training: Provide the 2014 edition of this training o Photo of your presentations of .
to at least 10 youth. Have those youth present the training to at least 1 this training to other groups.
group of 5(or more) youth in your community. The 2014 presentation
is available here: www.starttalkinanow.org/communifiesllets-draw-line- o Number of adults and youth who
2015 attending the training.
X Police Tip Line, LDTL style: Work with your local law enforcement to o Proof that tip line was
establish a "tip line"where information about underage drinking established or promoted.
activities can be given. If a general tip line already exists for your (i.e.: copy of print ad that runs in
community promote its use for enforcing underage drinking laws. newspaper)
Report on Local Justice System:What happens to individuals for o Interview law enforcement,
underage drinking offenses? prosecutors. Juvenile justice and
Court system personal to
develop a report about the
process.
o Present the report to a school
class.
(] LDTL Window Clings. Work with store owners/managers to have p Photos of window clings being
LDTL window clings put in over%of the stores where you conduct displayed.
CANS surveys. Leave a copy of theft/sales best practices document. o Number of stores in your
Order from. www.starttalkingnow.org/communitiesliets-draw-line-2015 community with LDTL window
clings.
Another Activity from the ATI Campaign. Select another Above the o Photos of the activity being
Influence Activity Toolkit. implemented.
Other Activity. Other activity that has been approved by DBHR. This o As determined and agreed to by
activity cannot involve"emotional appeal' strategies such as mock car DBHR.
crashes or"Every 15 Minutes."
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DSHS Central Contract Services
6015LF Custom tnterlocal Agreement(6-W9) Page V