ADES REFUGEE IGA AMD 9 (11) .PDF

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DEPARTMENT OF ECONOMIC SECURITY
Your Partner For A Stronger Arizona
Intergovernmental Agreement
CONTRACT AMENDMENT C-86-10-007-3-11
1. CONTRACTOR (Name and address} 2. CONTRACT ID NUMBER
DE101038-001
Maricopa County Department of Public Health
4041 N. Central Ave., Suite 1400 3. AMENDMENT NUMBER
9
Phoenix, AZ 85012
4. THE PARTIES AGREE TO THE FOLLOWING AMENDMENT
Pursuant to Section 3.0, Term of Agreement, Paragraph 3.2, Extension, the above referenced contract is extended
for the period of July 1, 2016 to June 30, 2017. The Health Assessment service rate is not adjusted for the extension
period and shall remain the same as for the previous contract term.
Pursuant to Section 4.0, Amendments or Modifications, the contract reimbursement ceiling for the “Coordination-
Refugee Preventive Health” service for the period of July 1, 2016 through June 30, 2017 is $210,812.
The cumulative reimbursement ceiling is revised to $2,948,165.
Therefore, the Itemized Service Budget for the period of July 1, 2016 to June 30, 2017 is attached.
5. EXCEPT AS PROVIDED HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT AS HERETOFORE CHANGED AND/OR
AMENDED REMAIN UNCHANGED AND IN FULL FORCE AND EFFECT. THE AMENDMENT SHALL BECOME EFFECTIVE ON THE DATE
OF LAST SIGNATURE UNLESS OTHERWISE SPECIFIED HEREIN. BY SIGNING THIS FORM ON BEHALF OF THE CONTRACTOR, THE
SIGNATORY CERTIFIES HE/SHE HAS THE AUTHORITY TO BIND THE CONTRACTOR TO THIS CONTRACT.
7, NAME OF CONTRACTOR Maricopa County by and through its
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Department of Public Heaith
SIGNATURE OF AUTHORIZED INDIVIDUAL SIGNATURE OF AUTHORIZED INDIVIDUAL
TYPED NAME TYPED NAME
Cynthia Pullen Clint Hickman
TITLE TITLE
Procurement Manager Chairman, Board of Supervisors
DATE DATE
IN ACCORDANCE WITH ARS §11-952 THIS CONTRACT AMENDMENT HAS BEEN REVIEWED BY THE UNDERSIGNED WHO HAVE DETERMINED THAT THIS
CONTRACT AMENDMENT IS IN APPROPRIATE FORM AND WITHIN THE POWERS AND AUTHORITY GRANTED TO EACH RESPECTIVE PUBLIC BODY.
ARIZONA ATTORNEY GENERAL'S OFFICE APPROVED AS TO FORM
By: By:
Assistant Attorney General Public Agency Legai Counsel
Attorney for Maricopa County
Date: Date:
ATTEST: Clerk of the Board Date

ITEMIZED SERVICE BUDGET
CONTRACT SERVICE: Coordination - Refugee Preventiv Health
CONTRACT: DE101038001
PROVIDER NAME: Maricopa County Department of Public Health Services
Division of Public Health Clinical Services
CONTRACT PERIOD: 07/01/2016 to 6/30/2017
1. PERSONNEL
TOTAL
,
Number of FTE Total Salary for the % Allocated Service SERVICE DAAS
Positions Level Position Title Contract Period *A + D= Total cost COST
4 1.00 Registered Nurse $53,892 5% + 95% = 100% $53,892 53,892
4 0.60 Ciient Service Coordinator $28,000 5% + 95% = 100% $28,000 28,000
1 0.70 X-RAY Tech $38,179 5% + 95% = 100% $38,179 38,179
TOTAL: 420,071 120,071
*A = % Administrative Functions D = % Direct Service Functions
2. EMPLOYEE RELATED EXPENSES TOTAL DAAS
ITEM Fixed Variable 19.21% COST COST
1 1.00 Registered Nurse $11,400 5% + 95% = 100% $§$ 21,753 §$ 21,753
4 0.60 CHient Service Coordinator $11,400 5% + 95% = 100% §$ 12,219 $ 12,219
4 0.70 X-RAY Tech $11,400 5% + 95% = 100% $ 15,314 $ 15,314
TOTAL: 49,286 49,286
3. PROFESSIONAL AND OUTSIDE SERVICES TOTAL DAAS
ITEM BASIS COST COST
TOTAL: - $0
4, TRAVEL TOTAL DAAS
ITEM BASIS COST COST
Staff Owned Vehicle Mileage Field visits 2846 miles @.56per mile $ 1,594 $ 4,594
TOTAL: 1,594.00 $1,594
§.SPACE TOTAL DAAS
ITEM BASIS cost COST
$0
TOTAL: - $0
§, EQUIPMENT TOTAL DAAS
ITEM BASIS COST COST
$0
TOTAL: - $0
7. MATERIALS AND SUPPLIES TOTAL DAAS
ITEM BASIS COST COST
$0
TOTAL: - $0
8. OPERATING SERVICES TOTAL DAAS
ITEM BASIS COST COST
Translation Services $ 12,205 $ 42,205
TOTAL: 42,205 $12,205
9, INDIRECT COSTS TOTAL BAAS
ITEM BASIS COST COST
Allocated Indirect 15.1% 27,656 27,656
TOTAL: 27,656 $27,656
10: “SUBTOTAL: ADMIN. COST. 210,812 210,812
-
11. VOUCHERS
TOTAL DAAS
TOTAL: ” $0
12: 2 TOTAL:SERVICE COST/DAAS TOTAL COST: 210,812: 2103812: