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HomeMy WebLinkAbout12-130 - Seattle King County Public Health - 2012 Rampart GrantPublic_ Health Seattle & King County LQ King County Contract No Federal Taxpayer ID No. 12-130 Council Approval N/A EMS2764 91- 6001519 This form is available in alternate formats for people with disabilities upon request. KING COUNTY CONTRACT FOR SERVICES WITH OTHER GOVERNMENT, INSTITUTION, OR JURISDICTION - 2012 Department Division Seattle -King County Dept. of Public Health (a.k.a. Public Health — Seattle & King Count /EMS Contractor City of Tukwila Project Title Rampart Contract Amount $4,000.00 Four Thousand Dollars and Zero Cents Contract Period Start date: 08/31/2012 End date: 12/31/2012 THIS CONTRACT is entered into by KING COUNTY (the "County "), and City of Tukwila (the "Contractor'), whose address is 6200 Southcenter Blvd, Tukwila, WA 98188. WHEREAS, the County has been advised that the following are the current funding sources, funding levels and effective dates: FUNDING SOURCES FUNDING LEVELS EFFECTIVE DATES COUNTY FEDERAL Federal Catalogue No. STATE OTHER: King County EMS Levy $4,000.00 08/31/2012 to 12/31/2012 TOTAL $4,000.00 and WHEREAS, the County desires to have certain services performed by the Contractor as described in this Contract, and as authorized by the 2012 Annual Budget. NOW THEREFORE, in consideration of payments, covenants, and agreements hereinafter mentioned, to be made and performed by the parties hereto, the parties covenant and do mutually agree as follows: Incorporation of Exhibits The Contractor shall provide services and comply with the requirements set forth in the following attached exhibits, which are incorporated herein by reference: A Program Exhibits and Requirements • Exhibit A: Scope of Work • Exhibit B: Budget • Exhibit C: Invoice B King County Required Forms • Exhibit D: Reporting Requirements • Exhibit E: Certificate of Insurance and Additional Insured Endorsement Contract # EMS2764 0 V d o a by Page # 1 of 9 Term and Termination A This Contract shall commence on 08/31/2012, and shall terminate on 12/31/2012, unless extended or terminated earlier, pursuant to the terms and conditions of the Contract. B This Contract may be terminated by the either party without cause, in whole or in part, prior to the date specified in Subsection II.A. above, by providing the other party thirty (30) days advance written notice of the termination. C The County may terminate this Contract, in whole or in part, upon seven (7) days advance written notice in the event: (1) the Contractor materially breaches any duty, obligation, or service required pursuant to this Contract, or (2) the duties, obligations, or services required herein become impossible, illegal, or not feasible. If the Contract is terminated by the County pursuant to this Subsection II.C. (1), the Contractor shall be liable for damages, including any additional costs of procurement of similar services from another source. If the termination results from acts or omissions of the Contractor, including but not limited to misappropriation, nonperformance of required services, or fiscal mismanagement, the Contractor shall return to the County immediately any funds, misappropriated or unexpended, which have been paid to the Contractor by the County. D If County or other expected or actual funding is withdrawn, reduced, or limited in any way prior to the termination date set forth above in Subsection II.A., the County may, upon written notification to the Contractor, terminate this Contract in whole or in part. If the Contract is terminated as provided in this Subsection: (1) the County will be liable only for payment in accordance with the terms of this Contract for services rendered prior to the effective date of termination; and (2) the Contractor shall be released from any obligation to provide such further services pursuant to the Contract as are affected by the termination. Funding or obligation under this Contract beyond the current appropriation year is conditional upon appropriation by the County Council of sufficient funds to support the activities described in the Contract. Should such appropriation not be approved, this Contract will terminate at the close of the current appropriation year. E Nothing herein shall limit, waive, or extinguish any right or remedy provided by this Contract or law that either party may have in the event that the obligations, terms, and conditions set forth in this Contract are breached by the other party. III Compensation and Method of Payment A The County shall reimburse the Contractor for satisfactory completion of the services and requirements specified in this Contract, payable in the following manner: Upon receipt and approval of a signed invoice as set forth in Exhibit C that complies with the budget in Exhibit B. B The Contractor shall submit an invoice and all accompanying reports as specified in the attached exhibits not more than 60 working days after the close of each indicated reporting period. The County will initiate authorization for payment after approval of corrected invoices and reports. The County shall make payment to the Contractor not more than 30 days after a complete and accurate invoice is received. C The Contractor shall submit its final invoice and all outstanding reports within 90 days of the date this Contract terminates. If the Contractor's final invoice and reports are not submitted by the day specified in this subsection, the County will be relieved of all liability for payment to the Contractor of the amounts set forth in said invoice or any subsequent invoice. D When a budget is attached hereto as an exhibit, the Contractor shall apply the funds received from the County under this Contract in accordance with said budget. The contract may contain Contract # EMS2764 Page # 2 of 9 separate budgets for separate program components. The Contractor shall request prior approval from the County for an amendment to this Contract when the cumulative amount of transfers among the budget categories is expected to exceed 10% of the Contract amount in any Contract budget. Supporting documents necessary to explain fully the nature and purpose of the amendment must accompany each request for an amendment. E If travel costs are contained in the attached budget, reimbursement of Contractor travel, lodging, and meal expenses are limited to the eligible costs based on the following rates and criteria. 1 The mileage rate allowed by King County shall not exceed the current Internal Revenue Service (IRS) rates per mile as allowed for business related travel. The IRS mileage rate shall be paid for the operation, maintenance and depreciation of individually owned vehicles for that time which the vehicle is used during work hours. Parking shall be the actual cost. When rental vehicles are authorized, government rates shall be requested. If the Contractor does not request government rates, the Contractor shall be personally responsible for the difference. Please reference the federal web site for current rates: http: / /www.gsa.gov. 2 Reimbursement for meals shall be limited to the per diem rates established by federal travel requisitions for the host city in the Code of Federal Regulations, 41 CFR § 301, App.A. 3 Accommodation rates shall not exceed the federal lodging limit plus host city taxes. The Contractor shall always request government rates. 4 Air travel shall be by coach class at the lowest possible price available at the time the County requests a particular trip. In general, a trip is associated with a particular work activity of limited duration and only one round -trip ticket, per person, shall be billed per trip. IV Internal Control and Accounting System The Contractor shall establish and maintain a system of accounting and internal controls which complies with applicable, generally accepted accounting principles, and governmental accounting and financial reporting standards. V Debarment and Suspension Certification Agencies receiving federal funds that are debarred, suspended, or proposed for debarment are excluded from contracting with the County. The Contractor, by signature to this Contract, certifies that the Contractor is not presently debarred, suspended, or proposed for debarment by any Federal department or agency. The Contractor also agrees that it will not enter into a subcontract with a contractor that is debarred, suspended, or proposed for debarment. The Contractor agrees to notify King County in the event it, or a subcontractor, is debarred, suspended, or proposed for debarment by any Federal department or agency. For more information on suspension and debarment, see Federal Acquisition Regulation 9.4. VI Maintenance of Records /Evaluations and Inspections A The Contractor shall maintain accounts and records, including personnel, property, financial, and programmatic records and other such records as may be deemed necessary by the County to ensure proper accounting for all Contract funds and compliance with this Contract. B In accordance with the nondiscrimination and equal employment opportunity requirements set forth in Section XIV. below, the Contractor shall maintain the following: 1 Records of employment, employment advertisements, application forms, and other pertinent data, records and information related to employment, applications for employment or the administration or delivery of services or any other benefits under this Contract; and 2 Records, including written quotes, bids, estimates or proposals submitted to the Contractor by all businesses seeking to participate on this Contract, and any other information necessary to document the actual use of and payments to subcontractors and suppliers in this Contract, including employment records. Contract # EMS2764 Page # 3 of 9 The County may visit, at any mutually agreeable time, the site of the work and the Contractor's office to review the foregoing records. The Contractor shall provide every assistance requested by the County during such visits. In all other respects, the Contractor shall make the foregoing records available to the County for inspection and copying upon request. If this Contract involves federal funds, the Contractor shall comply with all record keeping requirements set forth in any federal rules, regulations or statutes included or referenced in the contract documents. C Except as provided in Section VII of this Contract, the records listed in A and B above shall be maintained for a period of six (6) years after termination hereof unless permission to destroy them is granted by the Office of the Archivist in accordance with Revised Code of Washington (RCW) Chapter 40.14. D Medical records shall be maintained and preserved by the Contractor in accordance with state and federal medical records statutes, including but not limited to RCW 70.41.190, 70.02.160, and standard medical records practice. If the Contractor ceases operations under this Contract, the Contractor shall be responsible for the disposition and maintenance of such medical records. E The Contractor agrees to cooperate with the County or its agent in the evaluation of the Contractor's performance under this Contract and to make available all information reasonably required by any such evaluation process. The results and records of said evaluations shall be maintained and disclosed in accordance with RCW Chapter 42.56. F The Contractor agrees that all information, records, and data collected in connection with this Contract shall be protected from unauthorized disclosure in accordance with applicable state and federal law. VII Compliance with the Health Insurance Portability Accountability Act of 1996 ( HIPAA) The Contractor shall not use protected health information created or shared under this Contract in any manner that would constitute a violation of HIPAA and any regulations enacted pursuant to its provisions. Contractor shall read and certify compliance with all HIPAA requirements at http: / /www.kingcounty.gov /healthservices /health /partnerships /contracts VIII Audits A If the Contractor or subcontractor is a municipal entity or other government institution or jurisdiction, or is a non - profit organization as defined in OMB Circular A -133, and expends a total of $500,000 or more in federal financial assistance and has received federal financial assistance from the County during its fiscal year, then the Contractor or subcontractor shall meet the respective A -133 requirements described in subsections VIII.B. and VIII.C. B If the Contractor is a non - profit organization, it shall have an independent audit conducted of its financial statement and condition, which shall comply with the requirements of GAAS (generally accepted auditing standards); GAO's Standards for Audits of Governmental Organizations, Programs, Activities, and Functions; and OMB Circular A -133, as amended, and as applicable. The Contractor shall provide a copy of the audit report to each County division providing financial assistance to the Contractor no later than six (6) months subsequent to the end of the Contractor's fiscal year. The Contractor shall provide to the County its response and corrective action plan for all findings and reportable conditions contained in its audit. When reference is made in its audit to a "Management Letter" or other correspondence made by the auditor, the Contractor shall provide copies of those communications and the Contractor's response and corrective action plan. Submittal of these documents shall constitute compliance with subsection VIII.A. C If the Contractor is a municipal entity or other government institution or jurisdiction, it shall submit to the County a copy of its annual report of examination /audit, conducted by the Washington State Auditor, within thirty (30) days of receipt, which submittal shall constitute compliance with subsection VIII.A. D If the Contractor, for - profit or non - profit, receives in excess of $100,000 in funds during its fiscal year from the County, it shall provide a fiscal year financial statement prepared by an independent Contract # EMS2764 Page # 4 of 9 Certified Public Accountant or Accounting Firm within six (6) months subsequent to the close of the Contractor's fiscal year. E Additional audit or review requirements which may be imposed on the County will be passed on to the Contractor and the Contractor will be required to comply with any such requirements. IX Corrective Action If the County determines that a breach of contract has occurred, that is, the Contractor has failed to comply with any terms or conditions of this Contract or the Contractor has failed to provide in any manner the work or services agreed to herein, and if the County deems said breach to warrant corrective action, the following sequential procedure will apply: A The County will notify the Contractor in writing of the nature of the breach; The Contractor shall respond in writing within three (3) working days of its receipt of such notification, which response shall indicate the steps being taken to correct the specified deficiencies. The corrective action plan shall specify the proposed completion date for bringing the Contract into compliance, which date shall not be more than ten (10) days from the date of the Contractor's response, unless the County, at its sole discretion, specifies in writing an extension in the number of days to complete the corrective actions; B The County will notify the Contractor in writing of the County's determination as to the sufficiency of the Contractor's corrective action plan. The determination of sufficiency of the Contractor's corrective action plan shall be at the sole discretion of the County; C In the event that the Contractor does not respond within the appropriate time with a corrective action plan, or the Contractor's corrective action plan is determined by the County to be insufficient, the County may commence termination of this Contract in whole or in part pursuant to Section II.C.; D In addition, the County may withhold any payment owed the Contractor or prohibit the Contractor from incurring additional obligations of funds until the County is satisfied that corrective action has been taken or completed; and E Nothing herein shall be deemed *to affect or waive any rights the parties may have pursuant to Section II. Subsections B, C, D, and E. X Dispute Resolution The parties shall use their best, good -faith efforts to cooperatively resolve disputes and problems that arise in connection with this Contract. Both parties will make a good faith effort to continue without delay to carry out their respective responsibilities under this Contract while attempting to resolve the dispute under this section. XI Hold Harmless and Indemnification A In providing services under this Contract, the Contractor is an independent Contractor, and neither it nor its officers, agents, employees, or subcontractors are employees of the County for any purpose. The Contractor shall be responsible for all federal and /or state tax, industrial insurance, and Social Security liability that may result from the performance of and compensation for these services and shall make no claim of career service or civil service rights which may accrue to a County employee under state or local law. The County assumes no responsibility for the payment of any compensation, wages, benefits, or taxes by, or on behalf of the Contractor, its employees, subcontractors and /or others by reason of this Contract. The Contractor shall protect, indemnify, and save harmless the County, its officers, agents, and employees from and against any and all claims, costs, and /or losses whatsoever occurring or resulting from (1) the Contractor's failure to pay any such compensation, wages, benefits, or taxes, and /or (2) the supplying to the Contractor of work, services, materials, or supplies by Contractor employees or other suppliers in connection with or support of the performance of this Contract. Contract # EMS2764 Page # 5 of 9 B The Contractor further agrees that it is financially responsible for and will repay the County all indicated amounts following an audit exception which occurs due to the negligence, intentional act, and /or failure, for any reason, to comply with the terms of this Contract by the Contractor, its officers, employees, agents, or subcontractors. This duty to repay the County shall not be diminished or extinguished by the prior termination of the Contract pursuant to the Duration of Contract or the Termination section. C The Contractor shall defend, indemnify, and hold harmless the County, its officers, employees, and agents from any and all costs, claims, judgments, and /or awards of damages, arising out of, or in any way resulting from, the negligent acts or omissions of the Contractor, its officers, employees, subcontractors and /or agents in its performance or non - performance of its obligations under this Contract In the event the County incurs any judgment, award, and /or cost arising therefrom including attorneys' fees to enforce the provisions of this article, all such fees, expenses, and costs shall be recoverable from the Contractor. D The County shall defend, indemnify, and hold harmless the Contractor, its officers, employees, and agents from any and all costs, claims, judgments, and /or awards of damages, arise out of, or in any way result from, the negligent acts or omissions of the County, its officers, employees, or agents in its performance or non - performance of its obligations under this Contract. In the event the Contractor incurs any judgment, award, and /or cost arising therefrom including attorneys' fees to enforce the provisions of this article, all such fees, expenses, and costs shall be recoverable from the County. E Claims shall include, but not be limited to, assertions that use or transfer of software, book, document, report, film, tape, or sound reproduction or material of any kind, delivered hereunder, constitutes an infringement of any copyright, patent, trademark, trade name, and /or otherwise results in unfair trade practice. F Nothing contained within this provision shall affect and /or alter the application of any other provision contained within this Contract. G The indemnification, protection, defense and save harmless obligations contained herein shall survive the expiration, abandonment or termination of this Agreement. XII Insurance Requirements By the date of execution of this Contract, the Contractor shall procure and maintain for the duration of this Contract, insurance against claims for injuries to persons or damages to property which may arise from, or in connection with, the performance of work hereunder by the Contractor, its agents, representatives, employees, and /or subcontractors. The costs of such insurance shall be paid by the Contractor or subcontractor. The Contractor may furnish separate certificates of insurance and policy endorsements for each subcontractor as evidence of compliance with the insurance requirements of this Contract. The Contractor is responsible for ensuring compliance with all of the insurance requirements stated herein. Failure by the Contractor, its agents, employees, officers, subcontractors, providers, and /or provider subcontractors to comply with the insurance requirements stated herein shall constitute a material breach of this Contract. Specific coverages and requirements are at http: / /www.kingcounty.gov /healthservices /health /partnerships /contracts; contractors shall read and certify compliance. XIII Assignment /Subcontracting A The Contractor shall not assign or subcontract any portion of this Contract or transfer or assign any claim arising pursuant to this Contract without the written consent of the County. Said consent must be sought in writing by the Contractor not less than fifteen (15) days prior to the date of any proposed assignment. B "Subcontract" shall mean any agreement between the Contractor and a subcontractor or between subcontractors that is based on this Contract, provided that the term "subcontract" does not include the purchase of (1) support services not related to the subject matter of this Contract, or (2) supplies. Contract # EMS2764 Page # 6 of 9 C The Contractor shall include Sections III.D., IV, V, VI, VII, VIII, XI, XII, XIV, XV, XXI, and XXV, in every subcontract or purchase agreement for services that relate to the subject matter of this Contract. D The Contractor agrees to include the following language verbatim in every subcontract, provider agreement, or purchase agreement for services which relate to the subject matter of this Contract: "Subcontractor shall protect, defend, indemnify, and hold harmless King County, its officers, employees and agents from any and all costs, claims, judgments, and /or awards of damages arising out of, or in any way resulting from the negligent act or omissions of subcontractor, its officers, employees, and /or agents in connection with or in support of this Contract. Subcontractor expressly agrees and understands that King County is a third party beneficiary to this Contract and shall have the right to bring an action against subcontractor to enforce the provisions of this paragraph." XIV Nondiscrimination and Equal Employment Opportunity The Contractor shall comply with all applicable federal, state and local laws regarding discrimination, including those set forth in this Section. During performance of the Contract, the Contractor agrees that it will not discriminate against any employee or applicant for employment because of the employee or applicant's sex, race, color, marital status, national origin, religious affiliation, disability, sexual orientation, gender identity or expression or age except by minimum age and retirement provisions, unless based upon a bona fide occupational qualification. The Contractor will make equal employment opportunity efforts to ensure that applicants and employees are treated, without regard to their sex, race, color, marital status, national origin, religious affiliation, disability, sexual orientation, gender identity or expression or age. Additional requirements are at http:// www .kingcounty.gov /healthservices /health /partnerships /contracts; contractors shall read and certify compliance. XV Conflict of Interest A The Contractor agrees to comply with applicable provisions of K.C.C. 3.04. Failure to comply with such requirements shall be a material breach of this contract, and may result in termination of this Contract pursuant to Section II and subject the Contractor to the remedies stated therein, or otherwise available to the County at law or in equity. B The Contractor agrees, pursuant to KCC 3.04.060, that it will not willfully attempt to secure preferential treatment in its dealings with the County by offering any valuable consideration, thing of value or gift, whether in the form of services, loan, thing or promise, in any form to any county official or employee. The Contractor acknowledges that if it is found to have violated the prohibition found in this paragraph, its current contracts with the county will be cancelled and it shall not be able to bid on any county contract for a period of two years. C The Contractor acknowledges that for one year after leaving County employment, a former county employee may not have a financial or beneficial interest in a contract or grant that was planned, authorized, or funded by a county action in which the former county employee participated during county employment. Contractor shall identify at the time of offer current or former County employees involved in the preparation of proposals or the anticipated performance of Work if awarded the Contract. Failure to identify current or former County employees involved in this transaction may result in the County's denying or terminating this Contract. After Contract award, the Contractor is responsible for notifying the County's Project Manager of current or former County employees who may become involved in the Contract any time during the term of the Contract. XVI Equipment Purchase Maintenance, and Ownership A The Contractor agrees that any equipment purchased, in whole or in part, with Contract funds at a cost of $5,000 per item or more, when the purchase of such equipment is reimbursable as a Contract budget item, is upon its purchase or receipt the property of the County and /or Contract # EMS2764 Page # 7 of 9 federal /state government. The Contractor shall be responsible for all such property, including the proper care and maintenance of the equipment. B The Contractor shall ensure that all such equipment will be returned to the County or federal /state government upon termination of this Contract unless otherwise agreed upon by the parties. XVII Proprietary Rights The parties to this Contract hereby mutually agree that if any patentable or copyrightable material or article should result from the work described herein, all rights accruing from such material or article shall be the sole property of the party that produces such material or article. If any patentable or copyrightable material or article should result from the work described herein and is jointly produced by both parties, all rights accruing from such material or article shall be owned in accordance with US Patent Law. Each party agrees to and does hereby grant to the other party, irrevocable, nonexclusive, and royalty -free license to use, according to law, any material or article and use any method that may be developed as part of the work under this Contract. The foregoing products license shall not apply to existing training materials, consulting aids, checklists, and other materials and documents of the Contractor which are modified for use in the performance of this Contract. The foregoing provisions of this section shall not apply to existing training materials, consulting aids, checklists, and other materials and documents of the Contractor that are not modified for use in the performance of this Contract. XXIII Political Activity Prohibited None of the funds, materials, property, or services provided directly or indirectly under this Contract shall be used for any partisan political activity or to further the election or defeat of any candidate for public office. XIX King County Recycled Product Procurement Policy In accordance with King County Code 10.16, the Contractor shall use recycled paper for the production of all printed and photocopied documents related to the fulfillment of this Contract. In addition, the Contractor shall use both sides of paper sheets for copying and printing and shall use recycled /recyclable products wherever practical in the fulfillment of this Contract. XX Future Support The County makes no commitment to support the services contracted for herein and assumes no obligation for future support of the activity contracted herein except as expressly set forth in this Contract. XXI Entire Contract/Waiver of Default The parties agree that this Contract is the complete expression of the terms hereto and any oral or written representations or understandings not incorporated herein are excluded. Both parties recognize that time is of the essence in the performance of the provisions of this Contract. Waiver of any default shall not be deemed to be a waiver of any subsequent default. Waiver or breach of any provision of the Contract shall not be deemed to be a waiver of any other or subsequent breach and shall not be construed to be a modification of the terms of the Contract unless stated to be such through written approval by the County, which shall be attached to the original Contract. XXII Contract Amendments Either party may request changes to this Contract. Proposed changes which are mutually agreed upon shall be incorporated by written amendments to this Contract. XXIII Notices Whenever this Contract provides for notice to be provided by one party to another, such notice shall be in writing and directed to the chief executive office of the Contractor and the project representative of the Contract # EMS2764 Page # 8 of 9 County department specified on page one of this Contract. Any time within which a party must take some action shall be computed from the date that the notice is received by said party. XXIV Services Provided in Accordance with Law and Rule and Regulation The Contractor and any subcontractor agree to abide by the laws of the state of Washington, rules and regulations promulgated thereunder, and regulations of the state and federal governments, as applicable, which control disposition of funds granted under this Contract, all of which are incorporated herein by reference. In the event that there is a conflict between any of the language contained in any exhibit or attachment to this Contract, the language in the Contract shall have control over the language contained in the exhibit or the attachment, unless the parties affirmatively agree in writing to the contrary. XXV Applicable Law This contract shall be construed and interpreted in accordance with the laws of the State of Washington. The venue for any action hereunder shall be in the Superior Court for King County, Washington. XXVI No Third Party Beneficiaries Except for the parties to whom this contract is assigned in compliance with the terms of this contract, there are no third party beneficiaries to this contract, and this contract shall not impart any rights enforceable by any person or entity that is not a party hereto. IN WITNESS HEREOF, the parties hereby agree to the terms and conditions of this Contract: KING COUNTY FOR King County Executive Date City of Tukwila &, kA:b -:30 2D /ma- Date Approved as to Form: OFFICE OF THE KING COUNTY PROSECUTING ATTORNEY PHSKC Contract # EMS2764 - Rampart Contract # EMS2764 Page # 9 of 9 Contract EMS2764 Exhibit A - Scope of Work KING COUNTY EMERGENCY MEDICAL SERVICES DIVISION King County Project RAMPART Appendix A - Funding Application (PLEASE PRINT) Applicant Sponsor Name: Erika Eddins Title: Human Resources Assistant City: Tukwila Address: 6200 Southcenter Boulevard City: Tukwila Zip: 98198 Name of signature authority for RAMPART Agency Services Contract: Jim Haggerton, Mayor Name of Agency RAMPART primary contact (Liaison to EMS Division ): Erika Eddins Telephone: 206 -433 -1816 Email address: erika.eddins @tukwilawa.Rov Mailing Address: 6200 5outhcenter Boulevard City: Tukwila , Number of FTE's in city government: 3171:" /-N Approximate Approximate number of employees to be trained in 2012: 50 (August through Dec, 2012) ✓ Due Date: Friday, August 3, 2012 Email to: Leah.doctorelloQkin counly.gov (preferred method) Or mail to: Leah Doctorello, Community Programs King County Emergency Medical Services 401-5 th Ave., Suite 1200 Seattle, WA 98104 Grant applications will be reviewed by Project RAMPART program staff. Cities chosen to participate for 2012 will be determined by degree of ability to meet the scope of the Project Responsibilities as indicated on page 2 of the application. Notification of awards will be made by Friday, August 10, 2012. Awarded contracts will be ready as soon as practical. Planning and coordination with RAMPART staff may continue during the interim while contracts are being prepared. Appendix A (Page 2) - SCOPE OF RESPONSIBILITY ABILITY TO MEET SCOPE (Please place an X in the column that best fits your city's ability to meet the scope of Prniart RAMPART- if fundine is eranted. Responsibility of Municipality Can Can Cannot Responsibility of King County (King (The Agency) fully partially meet County is prepared to meet all meet meet Scope responsibilities listed below.) Scope Scope Provide a Project Rampart liaison to Provide a Project RAMPART Program coordinate with King County. ❑O ❑ ❑ Manager liaison to coordinate with each Municipality. Provide training in CPR /AED to city Provide training to King County employees. This training can be employees. reimbursed by Project Rampart as © ❑ ❑ follows: $46.00 per hour for a maximum of 1 instructor per class: • 3 hour maximum for Basic CPR Training; • 2 hour maximum for Refresher Training (every 2 years); Additional cost for training above these caps must be paid for by The Agency. Coordinate your city Public Access Coordinate the KC Public Access Defibrillation efforts. ® ❑ ❑ Defibrillation Program. Conduct PAD Public Awareness Campaign as directed in the EMS 2008 -2013 Strategic Plan. Ensure that all newly placed AEDs within Maintain King County PAD Registry. your city government facilities are © ❑ ❑ Ensure that all AEDs in King County registered with King County PAD Registry. government facilities are registered with the King County PAD Registry. Provide AED site coordination activities Provide AED site coordination activities related to proper placement, training and ® ❑ ❑ related to proper placement, training and maintenance of the AEDs for all the AEDs maintenance of the AEDs for all KC in public facilities. government AEDs in public facilities. Coordinate any private foundation, Provide incentive funding to Municipalities sponsorship, donation, and /or volunteer via contract. Funding allocation to be activities related to the purchase and ❑ ❑ ® based on city public erpployee count, placement of AEDs and AED training in number of public AEDs Registered. Pay private residences or private facilities quarterly invoices. within your city. Coordinate contract activities with KC Send Quarterly PAD Registry Reports to EMS to receive RAMPART funding. ® ❑ ❑ City Fire Departments Provide cardiac Submit quarterly invoices for arrest data for trending and Identification reimbursement, including original of high risk locations Invoices for all purchases and © ❑ ❑ Identification of high -risk locations within workforce training reports a Municipality. Contract EK4S2764 King County EMS Division Exhibit B, Project RAMPART Program Plan and Budget -2O1J City of Tukwila - RAMPART Funding allowance: __$4,00O__ Purchase AEDs Manufacturer Number of Cost per AED, Tot |Cmx Type* 8EOs include xxeUmoumt ForAEQ(s) includes: • AHAcams; ARC Cards 20 $2.I5 per card $45{0 • AEDTrainens; • Batteries,- Heartstart O $99.45 795.60 • Pads; Batteries • CPR Training Pads 17 $39.65 $39.65 supplies, etc. Miscellaneous Expenditures/Contingency $1886.57 Grand Total Budget $4000.00 levised 10/8/12 Tax Shipping Total AED (Approximate) Cost Total Cost, including Tax and Shipping I *Must purchase using WA State Contract #01710 (approx.. 30% discount)(Philips, Cardiac Science, or ZoU) **We do not recommend buying an extra battery at time of purchase because batteries last 4+ years. Training Estimated # of Estimated # Estimated number Hourly wage Total Employees to be ofCPR/AED of total class hours cap Training trained classes Cost Maximum allowable 50 Basic =2 6 $46.00/hour $276.00 CPR/AED class hours Basic Class = 3 hrs Refresher =2 4 35.79/hour $143.16 Training Supplies Type of Supply Number of Cost Total Cost of Items Training Suoolies includes: • AHAcams; ARC Cards 20 $2.I5 per card $45{0 • AEDTrainens; • Batteries,- Heartstart O $99.45 795.60 • Pads; Batteries • CPR Training Pads 17 $39.65 $39.65 supplies, etc. Miscellaneous Expenditures/Contingency $1886.57 Grand Total Budget $4000.00 levised 10/8/12 EMS276 Public Health —Seattle & King County Emergency Medical Services Division Project RAMPART EXHIBIT C—INVOICE AGENCY NAME DATE ADDRESS 0NTRAO# CITY STATE ZIP "PLEASE COMPLETE BOTH SECTIONS and SIGN BELOW" LINE ITEM BUDGET FUNDS EXPENDED TOTALFUNDS TOTAL BUDGET THIS TOTALFUNDS CATEGORIES THIS REPORT EXPENDED TO DATE YEAR REMAINING (include current report) INSTRUCTOR FEES Number of new AEDs placed in your jurisdiction and AED PURCHASES registered in KC PAD Registry Dollar amount of fundraising efforts for Public Access MISC. EQUIPMENT (Pads, Defibrillation in your community batteries, wall mounts, cabinets, etc) Attach List CPR/AED Training Supplies (includes AHA cards) Attach List TOTAL ACCOMPLISHMENT REPORT CERTIFICATION FOR PAYMENT 1, the undersigned, do hereby certify that the materials have been furnished, the services rendered or the labor performed as described herein, and that the claim is a just, due and unpaid obligation against the County of King, and that I am authorized to authenticate and certify to said claim. Agency Representative Signature Agency Representative Print Name Date Submit to: King County Emergency Medical Services Attn: Anne Curtis 206-263'8317 401 Fifth Ave. Suite 1200 Seattle, VVAQ8104 Revised 8/22/12 TOTAL TYPE OF ACTIVITY CURRENT REPORT TO DATE (include current Number of city employees trained Number of AEDs purchased with RAMPART funds (King County Contract funds) Number of new AEDs placed in your jurisdiction and registered in KC PAD Registry Dollar amount of fundraising efforts for Public Access Defibrillation in your community CERTIFICATION FOR PAYMENT 1, the undersigned, do hereby certify that the materials have been furnished, the services rendered or the labor performed as described herein, and that the claim is a just, due and unpaid obligation against the County of King, and that I am authorized to authenticate and certify to said claim. Agency Representative Signature Agency Representative Print Name Date Submit to: King County Emergency Medical Services Attn: Anne Curtis 206-263'8317 401 Fifth Ave. Suite 1200 Seattle, VVAQ8104 Revised 8/22/12 Comtract#EMS2764 Public Health — Seattle & King County Emergency Medical Services — Project RAMPART 2012 EXH|B|TO — ControctReportingRequirements The Agency shall comply with the following reporting requirements during the contract period: A. invoices shall be submitted for reimbursement of Project RAMPART expenses quarterly, and no later than April 15m,]uly1Sth, Sept 1cm and December ZOm. B. Documentation of Instructor Fees: 1) A course roster for each [PR\AED course taught to city employees must besubmitted with the RAMPART invoice. The course roster must include 1)|nstructor name, 2)date nf class, 3)type of the class taught, and 4) the number hours of instruction taught. 2) This training can bo reimbursed ata maximum of$4G per hour for one instructor. If course size is over 15 students, one additional instructor may be brought in for the 2 nd or] d hour of the class for practical work onmanikins. \f payment of instructors must exceed $46 per hour, the agency must pay that extra cost. B. AED Purchases l) You may purchase AEDs using pricing from the VVA State contract #O171O. More information and price lists are available on . Just put the contract # on your Purchase Order for the vendor of your choice and you should get reduced pricing. After delivery, include the original vendor invoice with your RAMPART Invoice for reimbursement. At minimum, we recommend purchase of 1 wall mount, 1 carrying case and 1 extra set of pads for each AEDpurchased. VVedo not recommend buying an extra battery at the time of AED purchase, because they have a life of about 4yeans. You may buy batteries for Project RAMPART for AEDs purchased inprevious years. C. Miscellaneous Equipment/Supplies and CPR\AED Training Supplies 1) Provide an itemized list of all equipment and supplies purchased and list the price of each item. Include an original vendor invoice attached to the RAMPART invoice. The Project RAMPART contract is a reimbursable contract and all purchases and services must be completed prior to invoicing King County. Invoices must be mailed to Linda CuUey,Manager, Community Programs, King County EMS, 4O1 Fifth Ave, Suite 12OO, Seattle, VVA 98104. All required reports described above must accompany invoice. Invoices are due no later than 15 calendar days following the end of the 1*,Z" o & 3 m calendar quarter and due on December 2(ƒ h for the 4th calendar quarter. Revised 8/23/12 Insurance Auttiority P.O. Box 88030 31-Oct-12 Public Health - Seattle & King County Attn: 401 5th Ave., Suite 1300 Seattle, WA 98104 RE: City of Tukwila Grant Contract Evidence of Coverage Cert#: 8031 The above captioned entity is a member of the Washington Cities Insurance Authority (WCIA), which is a self insured pool of over 150 public entities in the State of Washington. 'Fulmila, WA 981,38 Phone: 206-575-6046 Nax: 206-575-7426 WCIA has at least $1 million per occurrence limit of liability coverage in its self insured layer that may be applicable in the event an incident occurs that is deemed to be attributed to the negligence of the member. WCIA was created by an interlocal agreement among public entities and liability is self funded by the membership. As there is no insurance policy involved and WCIA is not an insurance company, your organization cannot be named as an additional insured. Sincerely, -e6 2— Eric B. Larson Deputy Director cc: Peggy McCarthy Erika Eddins cletter Form "9 Request for Taxpayer Give Form to the (Rev. January 2011) Identification Number and Certification requester' Do not send to the 1RS. Department of the Treasury Internal Revenue Service Name (as shown on your Income tax return) City of Tukwila C i Business name /disregarded entity name, if different from above as rn Check appropriate box for federal tax 0 classification (required): ❑Individual /sole proprietor W1 C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate a C 0 ❑Exempt payee ❑ Limited liability company. Enter the tax classification ( C =C corporation, S =S corporation, P= annershl p) Y o IL ❑ Other (see instructions) Address (number, street, and apt, or suite no.) Requester's name and address (optional} 6200 Southcenter Blvd City, state, and ZIP code Tukwila, WA 98188 List account number(s) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line Social security number E re avoid backup withholding. For Individuals, this is your social security number n page However, fora resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For, other antitiac. if is vnur amninver identification number (EiNI. If you do not have a number. see How to net a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose I Employer identification number number to enter. 1 9 1— 6 8 1 0 1 1 1 5 1 1 1 9 Under penalties of perjury, I certify that: 1. The number shown on this form Is my correct taxpayer Identification number (or I am waiting for a number to be issued to me), and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. 1 am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on Dane 4. argfrr Signature of Here I U.S. person )O, _ �q �� tl Date I* General Instructions U Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W -9 only If you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be Issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S, exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership Income from a U.S. trade or business is not subject to the withholding tax an foreign partners' share of effectively connected Income. Note. If a requester gives you a form other than Form W -9 to request your TIN, you must use the requester's form If It is substantially similar to this Form W -9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined In Regulations section 301.7701 -7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, in certain cases where a Form W -9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W -9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No. 10231X Form W-9 (Rev. 1 -2011) PUBLIC HEALTH CONTRACTOR CERTIFICATION STATEMENT REGARDING TERMS AND CONDITIONS Please print out this page, complete the certification statement below, to include the contract number and return the signed page to the address at the bottom of this page. I certify that I have read and understand the EEO/Non-Discrimination, HIPAA and Insurance contracting requirements on the Public Health website h!tp://www,kiri�ur)t.,,c ov/h,ealth/contracts, and I agree to comply with all of the contract terms and conditions detailed on that site. Contract #: C'� Agency Name: Agency Addws: Signature: Date: / 0 Printed Name &Title: d I/ )S' SS Return this completed page to: Contracts Section Public Health — Seattle & King County 401 Fifth Avenue, Suite 1300 Seattle, WA 98104