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CONTRACT NO: 200234 AMENDMENTNO: 3 AMENDMENT TO CONTRACT Between MARICOPA COUNTY By and Through DEPARTMENT OF PUBLIC HEALTH and DIGNITY COMMUNITY CARE lL. The above-named contract is hereby amended as specified below: A. Contract Expiration date shall be updated to August 18, 2025. B. Compensation shall be updated as follows: i. Contractor shall only be reimbursed for the Administration fee for vaccines provided by MCDPH. MCDPH will not reimburse for vaccines purchased by the Contractor. ii. Contractor shall submit a detailed monthly invoice within 30 days following the event. The invoice must have a Task Order Number associated with it. Failure to submit invoices within 30 days of the completed event or without a Task Order Number associated with it may result in reimbursements being denied. C. Scope of Work, shall be updated as follows: i. This Contract is for events outside the Contractor's normal clinic operations unless prior approval is received in writing by MCDPH. If Contractor would like to host an event at their facility, Contractor must seek prior authorization from MCDPH, and the event must be open to the general public in order to seek reimbursement. ii. The Contractor must provide an End-of-Event report within 7 days of the event. The report can be found at https://phvts.maricopa.gov and is attached as shown beginning on page 3 of this Amendment. iii. The Contractor must complete a Task Order request form for any new events they plan on seeking reimbursement for. If the Contractor plans to extend the event date past the final date in the previously submitted Task Order form, a new Task Order form must be submitted. The form can be found at MCDPH Event Task Order Form and is attached as beginning on page 5 of this Amendment. D. Term and Conditions shall be updated to include: i. WRITTEN CERTIFICATION PURSUANT to A.R.S. § 35-393.01: If Contractor engages in for-profit activity and has 10 or more employees, and if this agreement has a value of $100,000 or more, Contractor certifies it is not currently engaged in, and agrees for the duration of this agreement to not engage in, a boycott of goods or services from Israel. This certification does not apply to a boycott prohibited by 50 U.S.C. § 4842 or aregulation issued pursuant to 50 U.S.C. § 4842. [238675].274091 1482536 Page 1 of 8 ii, WRITTEN CERTIFICATION PURSUANT to A.R.S. § 35-394: Contractor warrants and certifies that it does not currently, and agrees for the duration of the Agreement, that it will not use: 1. 2. 3. Il. All other terms and cond the forced labor of ethnic Uyghurs in the People's Republic of China, any goods or services produced by the forced labor of ethnic Uyghurs in the People's Republic of China, any contractors, subcontractors or suppliers that use the forced labor or any goods or services produced by the forced labor of ethnic Uyghurs in the People's Republic of China. If Contractor becomes aware during the term of this Agreement that the Contractor is not in compliance with this paragraph, Contractor shall notify the County within five business days after becoming aware of the noncompliance. If the Contractor fails to provide a written certification to the County that the Contractor has remedied the noncompliance within 180 days after notifying the County of its noncompliance, then the agreement terminates, except that if the agreement termination date occurs before the end of the 180-day period, the agreement terminates on the agreement termination date. itions of the original contract shall remain in full force and effect. IN WITNESS WHEREOF, the parties agree to the changes indicated herein: FOR AND ON BEHALF OF FOR AND ON BEHALF OF MARICOPA COUNTY DIGNITY COMMUNITY CARE By: By: ful Ave Chairman, Board of Supervisors Dignity’ Community Care7 Prectutint CE Date Date 4|zu|24 ATTEST Clerk of the Board Date APPROVED AS TO FORM Attorney for Maricopa County Date [238675].274091 .1482536 Page 2 of 8 Vaccine Events Task Order Submission Form rust oe ed ouy ve thse dohiewicy fee event Siitiaty XY clays How eMtiNeH. tertbes Mibtad be sue uta e mined fun cert es ate ee out, OO days, vo rst Tase Ode Narae *Vendor and Contact Infarmation VerdovAgercy Nate ea dalCoitact Nane ta-ndalConactina Addess Pact af Guntact aie Nar ue * Date and Time of event Deet Jae StaiT re bit * vent Location Details acaba Nace (Soe, fas tess, etc} Siwet Addese Chitown Stateterae ice 22/Pasta Code * Vaccines Administered Tota Nate af COW D eace tee add istered Tata Narbe afd abe COV Dvaccirs dT tsteed Tata. Namae af Sov 3 View ee Age 134 St gety equested gat wl Tadatary) [238675].274091.1482536 aia ode ty! fon event Page 3 of 8 Tata Nurse af COV 2 Vacs tes Age 1217 11 gig -equested gut vat-tandatery} Tata Narae af COV 2 Vace tes Age SD Stgeng wquested gut at ranidatay} Tata: Natae af SOV 3 vac Age S routed gis equesied gut wtradaloy} Mansa cace es ade Tala Nave: at Tata Nuvae afd age Adat (Maeiwa wace ie: adr istered Tata Navoe af Adal egal ts Asacc ws: adr isteed Tota Navas aff ave legal fe maco tes ad istered Te g a4] Tata Narse af Adal stegat te ss adr ne steed Tata Nava afd agectegat ts Dace ms adr steed fe g se) Sea adcate ay caer fic eqatay © ogg al oie fis eee Tay ee ae tageted wa 2 OW Ware, Sate seas 1g, “4a, £12) Wee tree atyate wax Qeeida ag trseseit fes,acase stirs tas andiaas seaw Yeasts Saf Tyas acd tla s ofa ate mice we geet dacrigits een * Da you understand the fullowing?: «Vero Tas cude be Vaccaga Cowih a awe as fa owig aiguageatany Taetng rae a s THs a ate: susgacied traugafands tad) ae age oy Var coga County! Sea can ge found an tie Se * Tetp ales, ates aid ceswces con oe faa ie Ys 3 © Foga vg tie eae Tas fart rast oe fed aot wt? days fa wig te ewe. cradd tay reaces bust ae cubT ted con igdateat tre eel fo reas ae nt sua ted wit 1 i0days, your se ae ag e bouree te for tre eet Cl cae ead aed aidesstand te eqacere tts of ge ga eerdae nnata 92m [238675].274091.1482536 Page 4 of 8 Task Order Assignment Form This form is intended for Public Health personnel, Maricopa County Vendors, and |GA Partners to submit their events for approval and for atask order number. Any invoice submitted to us without the proper task order number will result in you not being reimbursed for your events. cheryl. bucalo@maricopa.gov Switch sccourt &% Not shared a * Indicates required question Vendor Company Name * Your answer Your Name * Your answer Your Email * Your answer Event Name Your answer [238675].274091.1482536 Page 5 of 8 Address * Your answer City * Your answer Zip Code * Your answer Dates for this Event « Your answer Hours of Operation * Your answer [238675].274091.1482536 Page 6 of 8 What Vaccines will be Administered? * Moderna (ages 6 months - 5) Moderna (ages 6 - 11) Moderna (ages 12+) Moderna Bivalent Booster (ages 6+) IO OOO Pfizer (ages 6 months - 4) OO Pfizer (ages 5- 11) Pfizer (ages 12+) Pfizer Bivalent Booster (ages 5+) Janssen (ages 18+) Flu Vaccines Other: OOOO Will this event be targeted toward specific equitable populations? * ©) Yes © No This isa... * ©) Pop-Up Vaccine Event ©) Long Term Care Facility ©) Assisted Living Facility (@) Other: [238675].274091 .1482536 Page 7 of 8 Would you like us to advertise this event on our Maricopa County Vaccine Finder * Calendar? oO Yes © No if you are targeting this event towards specific populations please list them here: Your answer Any further Information: Your answer Clear form Ihis contert sv ther cerated nor er dorsec ky Gaoghs. Menon sbuge: - Des of Google Forms [238675].274091 .1482536 Page 8 of 8