IGA AMD RE TEEN PREGNCY PREV WITH ADHS.PDF

ARIZONA DEPARTMENT OF
HEALTH SERVICES
1740 W. Adams, Room 303
INTERGOVERNMENTAL AGREEMENT (IGA)
Phoenix, Arizona 85007
AMENDMENT
(602) 542-1040
(602) 542-1741 Fax
Procurement Officer
Contract No: ADHS13-034430 Amendment No. 1
Tracy Chisler
Teen Pregnancy Prevention Program – Abstinence Plus
Effective January 1, 2014, it is mutually agreed that the IGA referenced is amended as follows:
1. Pursuant to the Scope of Work, Provision D., Tasks, the following tasks are revised to read as follows:
4.2 If offering youth development, the program needs to ensure integration between youth development
activities and teen pregnancy prevention curriculum education.
4.3 Program must obtain signed active parental consent form for youth to participate in the program and a
separate consent to participate in the evaluation.
6.1 Administering the ADHS pre/post evaluation tool to youth; and
All other provisions of this IGA remain unchanged.
CONTRACTOR SIGNATURE
Maricopa County Dept. of Public Health
Contractor Name Contractor Authorized Signature
4041 N. Central Ave., #1400
Address Printed Name
Phoenix AZ 85012
City State Zip Title
CONTRACTOR ATTORNEY SIGNATURE This Intergovernmental Agreement Amendment shall be effective the
Pursuant to A.R.S. § 11-952, the undersigned public agency attorney date indicated. The Public Agency is hereby cautioned not to commence
has determined that this Intergovernmental Agreement is in proper any billable work or provide any material, service or construction under
form and is within the powers and authority granted under the laws of this IGA until the IGA has been executed by an authorized ADHS
the State of Arizona. signatory.
State of Arizona
Signed this ______ day of _______________________ 2013
Signature Date
Printed Name Procurement Officer
RESERVED FOR USE BY THE SECRETARY OF STATE
Attorney General Contract No. P0012012000033, which is an
Agreement between public agencies, has been reviewed pursuant to Under House Bill 2011, A.R.S. § 11-952
A.R.S. § 11-952 by the undersigned Assistant Attorney General, who
has determined that it is in proper form and is within the powers and was amended to remove the requirement
authority granted under the laws of the State of Arizona. that Intergovernmental Agreements be filed
with the Secretary of State.
Signature Date
Assistant Attorney General
Printed Name:
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ARIZONA DEPARTMENT OF
HEALTH SERVICES
1740 W. Adams, Room 303
INTERGOVERNMENTAL AGREEMENT (IGA)
Phoenix, Arizona 85007
AMENDMENT (602) 542-1040
(602) 542-1741 Fax
Procurement Officer
Contract No: ADHS13-034430 Amendment No. 1
Tracy Chisler
2. Pursuant to the Scope of Work, Provision G., Deliverables, the following deliverables are revised to read as
follows:
2. A monthly narrative report (template provided by ADHS) of program activity services rendered, due the
10th of each month following the month of service (Exhibit Five (5)) and shall be approved by ADHS prior
to reimbursement;
3. Administer ADHS pre and post evaluation tool(s) to each participating youth and submit to ADHS within
five (5) days of completion of tool. In addition, programs implementing the Wyman Teen Outreach
Program® (TOP) will be required to administer the TOP® pre and post surveys and the ADHS pre/post
evaluation tool(s);
4. A monthly Contractor’s Expenditure Report (Exhibit Two (2)), due thirty (30) days following each month of
service, to be submitted electronically to the designated ADHS TPP Program Manager and shall be
approved by ADHS prior to reimbursement;
3. The Price Sheet of the IGA is replaced with the revised Price Sheet, Page Four (4) of this Amendment One (1).
The IGA Item Pricing shall be revised in ProcureAZ to align with available funding upon execution of this
Amendment One (1). The IGA line item pricing total remains the same at $229,837.00 based on the following line
item changes:
a. Professional and Outside Services will decrease by $13,000.00 for a total of $10,400.00 due to a change in
the evidence based curriculum in the middle of the grant year, which resulted in reducing the number of
contracted facilitators needed from two (2) to one (1).
b. Travel Expenses will increase by $1,000.00 for a total of $3,500.00 due to new sites being added beyond
the Maryvale area of concentration, which will result in an increase in mileage reimbursement.
c. Operating Expenses will increase by $13,626.55 for a total of $31,647.04 due to a change in the evidence
based curriculum in the middle of the grant year which will result in an increase to the number of youth to be
served in more cycles, and the need to purchase additional incentives, snacks and materials.
d. Indirect (if authorized) will decrease by $1,626.55 for a total of $31,359.45 due to a reduction of the
percentage rate from the previous year.
4. Pursuant to the Terms and Conditions, Provision 4.12 of the IGA, Scrutinized Businesses, is hereby deleted in its
entirety.
5. Pursuant to Terms and Conditions, Provision Fifteen (15) of the IGA, Fingerprint and Certification
Requirements/Juvenile Services, is hereby deleted in its entirety.
6. Pursuant to the Terms and Conditions, Provision Eighteen (18), Health Insurance Portability and Accountability
Act of 1996 of the IGA is hereby replaced with the following language:
18. The Contractor warrants that it is familiar with the requirements of HIPAA, as amended by the Health
Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009, and accompanying
regulations and will comply with all applicable HIPAA requirements in the course of this Contract.
Contractor warrants that it will cooperate with the Arizona Department of Health Services (ADHS) in the
course of performance of the Contract so that both ADHS and Contractor will be in compliance with HIPAA,
including cooperation and coordination with the Arizona Strategic Enterprise Technology (ASET) Office,
Statewide Information Security and Privacy Office (SISPO) Chief Privacy Officer and HIPAA Coordinator
and other compliance officials required by HIPAA and its regulations. Contractor will sign any documents
that are reasonably necessary to keep ADHS and Contractor in compliance with HIPAA, including, but not
limited to, business associate agreements.
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ARIZONA DEPARTMENT OF
HEALTH SERVICES
1740 W. Adams, Room 303
INTERGOVERNMENTAL AGREEMENT (IGA)
Phoenix, Arizona 85007
AMENDMENT (602) 542-1040
(602) 542-1741 Fax
Procurement Officer
Contract No: ADHS13-034430 Amendment No. 1
Tracy Chisler
If requested by the ADHS Procurement Office, Contractor agrees to sign a “Pledge To Protect Confidential
Information” and to abide by the statements addressing the creation, use and disclosure of confidential
information, including information designated as protected health information and all other confidential or
sensitive information as defined in policy. In addition, if requested, Contractor agrees to attend or
participate in HIPAA training offered by ADHS or to provide written verification that the Contractor has
attended or participated in job related HIPAA training that is: (1) intended to make the Contractor proficient
in HIPAA for purposes of performing the services required and (2) presented by a HIPAA Privacy Officer or
other person or program knowledgeable and experienced in HIPAA and who has been approved by the
ASET/SISPO Chief Privacy Officer and HIPAA Coordinator.
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ARIZONA DEPARTMENT OF
HEALTH SERVICES
1740 W. Adams, Room 303
INTERGOVERNMENTAL AGREEMENT (IGA)
Phoenix, Arizona 85007
AMENDMENT (602) 542-1040
(602) 542-1741 Fax
Procurement Officer
Contract No: ADHS13-034430 Amendment No. 1
Tracy Chisler
Price Sheet
COST REIMBURSEMENT LINE ITEMS TOTAL AMOUNT
PERSONNEL $106,736.51
EMPLOYEE RELATED EXPENSES $46,194.00
PROFESSIONAL/OUTSIDE SERVICES $10,400.00
TRAVEL EXPENSES $3,500.00
OPERATING EXPENSES $31,647.04
INDIRECT (if authorized) $31,359.45
TOTAL $229,837.00
Note: The Contractor is authorized to transfer among line items up to ten percent (10%) of the total
budget amount as shown on the Price Sheet and shall have prior written approval from the ADHS
Program Manager. Any proposed transfer of funds among line items that exceeds ten percent (10%)
of the budget amount shall require a Contract Amendment. Transfer of funds from a funded line to a
non-funded line is not allowed without a Contract Amendment.
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