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STATE OF OREGON

COVER PAGE

Oregon Health Authority

STRATEGIES FOR POLICY AND ENVIRONMENTAL CHANGE, TOBACCO-FREE

(SPARC TOBACCO-FREE)

Request for Grant Applications (RFGA)

OHA-4127-15

Date of Issue: December 28, 2015

Closing Date: January 27, 2016 Single Point of Contact (SPC): Phillip McCoy, Contract Specialist Address: DHS/OHA Shared Services Office of Contracts and Procurement (OC&P) 250 Winter Street NE, 3rd floor, Rm 305 City, State, Zip: Salem Oregon 97302 Telephone: 503-945-5868 Facsimile 503-373-7889 E-mail: [email protected]

In compliance with the Americans with Disabilities Act, this document is available in

alternate formats such as Braille, large print, audio recordings, Web-based communications

and other electronic formats. To request an alternate format, please send an e-mail to dhs-

[email protected] or call 503-378-3486 (voice) or 503-378-3523 (TTY)

to arrange for the alternative format.

RFGA OHA-4127-15 PAGE 2 OF 79

TABLE OF CONTENTS SECTION 1: GENERAL INFORMATION ........................................................................................................ 3

1.1 INTRODUCTION ................................................................................................................................................................................................... 3 1.2 SCHEDULE ............................................................................................................................................................................................................... 4 1.3 SINGLE POINT OF CONTACT (SPC) .......................................................................................................................................................... 4

SECTION 2: AUTHORITY, OVERVIEW, AND SCOPE ............................................................................... 5 2.1 AUTHORITY ............................................................................................................................................................................................................ 5 2.2 DEFINITION OF TERMS ................................................................................................................................................................................... 5 2.3 OVERVIEW .............................................................................................................................................................................................................. 6 2.4 PROGRAM DESCRIPTION ............................................................................................................................................................................... 8

SECTION 3: PROCUREMENT REQUIREMENTS AND EVALUATION ................................................ 12 3.1 MINIMUM REQUIREMENTS ...................................................................................................................................................................... 12 3.2 MINIMUM SUBMISSION REQUIREMENTS ........................................................................................................................................ 12 3.3 PROCUREMENT PROCESS .......................................................................................................................................................................... 15 3.4 APPLICATION CONTENT REQUIREMENTS ..................................................................................................................................... 17 3.5 EVALUATION PROCESS ................................................................................................................................................................................ 23 3.6 POINT AND SCORE CALCULATIONS..................................................................................................................................................... 26 3.7 FINAL SELECTION ........................................................................................................................................................................................... 26

SECTION 4: AWARD AND NEGOTIATION .................................................................................................. 27 4.1 AWARD NOTIFICATION PROCESS ......................................................................................................................................................... 27 4.2 APPARENT SUCCESSFUL APPLICANT SUBMISSION REQUIREMENTS ........................................................................... 27 4.3 AGREEMENT NEGOTIATION .................................................................................................................................................................... 28

SECTION 5: ADDITIONAL INFORMATION ................................................................................................ 29 5.1 GOVERNING LAWS AND REGULATIONS ........................................................................................................................................... 29 5.2 OWNERSHIP/PERMISSION TO USE MATERIALS ......................................................................................................................... 29 5.3 CANCELLATION OF RFGA; REJECTION OF APPLICATIONS; NO DAMAGES. ................................................................ 29 5.4 COST OF SUBMITTING AN APPLICATION ......................................................................................................................................... 29 5.5 CHANGES/MODIFICATION AND CLARIFICATIONS .................................................................................................................... 29 5.6 RESERVATION OF OHA RIGHTS ............................................................................................................................................................. 30 5.7 AWARD NOTICE................................................................................................................................................................................................ 30 5.8 MODIFICATION OR WITHDRAWAL ..................................................................................................................................................... 30 5.9 RELEASE OF INFORMATION ..................................................................................................................................................................... 31 5.10 LIST OF ATTACHMENTS AND APPENDICES ................................................................................................................................... 31


SECTION 1: GENERAL INFORMATION

1.1 INTRODUCTION The State of Oregon, Oregon Health Authority (OHA), requests Applications from qualified Applicants to implement tobacco prevention and education strategies that address changing the retail environment to limit the influence of tobacco. This Request for Grant Applications (RFGA) is titled Strategies for Policy And enviRonmental Change, Tobacco-free (SPArC Tobacco-Free). Application is conditioned on OHA’s acceptance of any other terms and conditions or rights to negotiate any alternative terms and conditions that are not reasonably related to those expressly authorized for negotiation in the RFGA or Addenda. Local Public Health Authorities (LPHAs), Regional Health Equity Coalitions (RHECs), Tribal Health Agencies (THAs) and nonprofit health and social service organizations, or consortia of these entities, may submit only a single Application for this RFGA. A Consortium (defined in Section 2.2.2) must submit an Application by a single Lead Applicant, which shall be listed as the Applicant on the Application Cover Sheet (Attachment A), and represent jurisdiction-wide Local Program Plan strategies that are inclusive of all entities in the Consortium. If an LPHA is not the Lead Applicant, the LPHA must be a member of the Consortium. Each entity represented in the Consortium must submit a Letter of Commitment with the Consortium Application. If an organization submits an Application as a Consortium member, that organization is not permitted to submit a separate Application. LPHAs, RHECs, THAs, nonprofit health and social service organizations and similar organizations may be funded indirectly through the Application as sub-contractors of an Applicant or Consortium partners of an Applicant. All Applicants must attest that they will not finance the same scope of work under more than one Grant and that they will not supplant or duplicate existing local, state or federal funding for any activities within the Project description. See Application Cover Sheet (Attachment A), Item #9. OHA anticipates awarding between four (4) and ten (10) grants to LPHAs through the SPArC Tobacco-free RFGA opportunity. Awards are expected to range in size from $50,000 to $300,000 each. Each award amount is subject to negotiation by OHA and is dependent on the quality of Applications, proposed activities, size of intervention population, population size of the region served, geographic diversity, health burden of the intervention population, and likelihood of Applicant’s success in fulfilling plan strategies. OHA seeks Applicants who plan to work with an intervention population bearing a disproportionate burden of tobacco use and tobacco related health outcomes. OHA will make initial award decisions subject to OHA approval of Local Program Plans and budgets. Note: Following the initial grant awards, OHA reserves the right to make additional awards from this RFGA at any time during the currently anticipated program period of January 4, 2015 through June 30, 2017, if new or additional resources for the SPArC Tobacco-free become


available, and make reasonable adjustments to program period dates based on actual start times.

1.2 SCHEDULE The table below represents a tentative schedule of events. All times are listed in Pacific Time. All dates listed are subject to change.

Event Date Time Questions / Requests for Clarification Due January 5, 2016 10:00 AM Answers to Questions / Requests for Clarification Issued (approx.)

January 8, 2015

Closing (Applications Due) January 27, 2016 3:00 PM Issuance of Notice of Award (approx.) February 16, 2016

1.3 SINGLE POINT OF CONTACT (SPC)

The SPC for this RFGA is identified on the Cover Page, along with the SPC’s contact information. Applicant shall direct all communications related to any provision of the RFGA, whether about the technical requirements of the RFGA, Agreement requirements, the RFGA process, or any other provision only to the SPC.


SECTION 2: AUTHORITY, OVERVIEW, AND SCOPE

2.1 AUTHORITY OHA is issuing this RFGA pursuant to its authority under ORS 413.033.

2.2 DEFINITION OF TERMS For the purposes of this RFGA, capitalized words will refer to the following definitions.

2.2.1 General Definitions

Capitalized terms not specifically defined in this document are defined in OAR 125-246-0110.

2.2.2 Project Specific Definitions

Applicant means the entity that submits an Application in response to this RFGA. Application means a proposal by an eligible entity submitted to OCP in response to this RFGA. Consortium means a group of entities applying jointly for this RFGA, served by a lead applicant. A Consortium must include an LPHA, and may include multiple LPHAs and non-LPHA entities, such as Coordinated Care Organizations and Regional Health Equity Coalitions. Coordinated Care Organization (CCO) means a corporation, governmental agency, public corporation or other legal entity that is certified as meeting the criteria adopted by the Oregon Health Authority under ORS 414.625 to be accountable for care management and to provide integrated and coordinated health care for each of the organization’s members. (OAR 410-141-3000(21)). Local Public Health Authority (LPHA) means a county government, or a health district created under ORS 431.414 (district board of health) or a person or agency a county or health district has contracted with to act as the local public health authority. Public Health Financial Assistance Agreement (PH-FAA) means a series of separate agreements between OHA and various local government entities to include county and tribal governments pursuant to the requirements of ORS 431 for the purpose of supporting a wide range of local Public Health program and services. Tobacco-free Facility Policy Plan means a plan describing the steps being taken to adopt a tobacco-free facility policy by the end of the award period. Regional Health Equity Coalition (RHEC) means a community-driven collaborative group organized at a regional level to identify policy, system and environmental changes, and craft and implement strategies and polices to increase health equity, reduce health disparities and address the social determinants of health. (http://www.oregon.gov/oha/oei/Pages/rhec.aspx)

http://arcweb.sos.state.or.us/pages/rules/oars_100/oar_125/125_246.html


Tobacco-free Facility Policy means a written policy stating the entire facility property is 100% tobacco-free, including e-cigarettes, vape pens, e-hookah and other devices, is signed and implemented. The policy includes all interior, exterior and facility owned or controlled property, including vehicles, as areas that are tobacco-free at all times. Tribal Health Agency (THA) means a federally recognized Tribal government or Tribal organization. Recipient means the Applicant selected through this RFGA to enter into a Grant with OHA to perform the Program Activities in Section 3 Scope of Program Activities.

2.3 OVERVIEW

2.3.1 Project Background and Overview

2.3.1.1 Background

Tobacco is the leading preventable cause of death and disability, and one of the primary drivers of health care costs in Oregon. For the first time in Oregon, during the 2013 legislative session, Tobacco Master Settlement Agreement (TMSA) funds were designated for tobacco prevention. During the 2015 Oregon legislative session, these funds were allocated for tobacco prevention. The Oregon Health Authority (OHA) Health Promotion and Chronic Disease Prevention Section (HPCDP) consulted with the Conference of Local Health Officials (CLHO) and the Tobacco Reduction Advisory Committee (TRAC) regarding the allocation and distribution of TMSA funds in alignment with recommendations from the Centers for Disease Control and Prevention (CDC) Best-Practices for Tobacco Control. It was determined that a portion of TMSA funding is to be directed to Local Public Health Authorities (LPHAs), Tribal Health Agencies (THAs), Regional Health Equity Coalitions (RHECs) and nonprofit health and social service organizations to advance policy, systems and environmental changes that:

• Promote tobacco-free environments and communities, • Reduce the influence of tobacco in the retail environment, and • Encourage tobacco users to quit and keep youth from starting.

2.3.1.2 Overview

2.3.1.2.1 Application Development (General)

OHA seeks Applications from LPHAs, RHECs, THAs or nonprofit health and social service organizations, or consortia of these entities, to implement policy, systems and environmental tobacco prevention strategies designed to reduce the influence of tobacco in the retail environment and reduce tobacco use disparities in Oregon. Recipients will work with appropriate jurisdictions to adopt and implement a


tobacco control retail strategy rated as “recommended” (also called “green light”) by the Center for Public Health Science in the 2014 Point-of-Sale Strategies: A Tobacco Control Guide (http://publichealthlawcenter.org/sites/default/files/resources/tclc-guide-pos-policy-WashU-2014.pdf). In developing Applications, it is recommended for Applicants to collaborate with their local Coordinated Care Organization (CCO), Regional Health Equity Coalitions, Tribes, and other community organizations representing local populations disproportionately impacted by tobacco.

2.3.1.2.2 Consortium Option

LPHAs, RHECs, THAs, and nonprofit health and social service organizations may choose to join together to apply as Consortium as defined in Section 2.2.2 of this RFGA 4127. Each Consortium Application must be submitted by a single Lead Applicant and represent jurisdiction-wide Local Program Plan strategies that are inclusive of all entities in the Consortium. If an LPHA is not the Lead Applicant, an LPHA must be a member of the Consortium. Each entity represented in the Consortium must submit a Letter of Commitment with the Consortium Application. LPHAs, RHECs, THAs, nonprofit health and social service organizations and similar organizations, may be funded indirectly through the Application as sub-contractors of an Applicant or Consortium partners of an Applicant. An organization may submit only a single Application for this RFGA. A Consortium (defined in Section 1.6) must submit an Application under the name of a lead Applicant, in which case the lead Applicant shall be listed as the Applicant on the Application Cover Sheet (Attachment #1). If an organization submits an Application as a Consortium member, that organization is not permitted to submit a separate Application.

2.3.2 Purpose and Use of Funding by Awardees

Grant funding awarded pursuant to this RFGA will: • Complement, build upon, or accelerate, but not duplicate, the current Local Program Plan of the LPHA(s) Tobacco Prevention and Education Program (TPEP); • Be achievable and produce a sustainable change within the currently anticipated 18 month grant period of January 4, 2016 through June 30, 2017; and • Be able to demonstrate advancement of policy, systems and environmental changes in tobacco prevention and control in the retail environment. • Disseminate successful policies, lessons learned and evaluation findings to decision makers, elected bodies and public health stakeholders.


This RFGA will not fund: • Strategies that solely focus on increased knowledge or awareness as outcomes. • Strategies that solely focus on assessment or planning as the only outcomes.

(Assessment and planning can constitute part of the work but not the sole outcome of the grant.)

• Direct cessation services including medication, counseling, and incentives. • Paid media. • Work that duplicates or supplants existing tobacco use and prevention efforts.

2.4 PROGRAM DESCRIPTION

2.4.1 Scope and Description of Program Activities Activities described in this RFGA are within the scope of Program Element 13 (PE 13) – Tobacco Prevention and Education Program (TPEP) as published in the currently active series of OHA Public Health Division Financial Assistance Agreements (PH-FAA) with LPHAs for the Financing of Public Health Services. Accordingly, all activities described below will be subject to the provisions of PE 13 and the PH-FAA series and performed in a manner satisfactory to OHA. See Appendix A “Program Element 13 Tobacco Prevention and Education Program (TPEP)” for details. Activities include, but may not be limited to:

2.4.1.1 Implement Evidence-Based Strategies

Implement a Local Program Plan with one to three strategies for tobacco prevention policy, systems and environmental change that address tobacco in the retail environment. Recipients will work with appropriate jurisdictions to promote adoption and implementation of a “recommended” tobacco control retail strategy in the 2014 Point-of-Sale Strategies: A Tobacco Control Guide (http://publichealthlawcenter.org/sites/default/files/resources/tclc-guide-pos-policy-WashU-2014.pdf). Use existing community assessments (and conduct additional assessment activities as necessary) to determine and advance the selected strategy; and select strategies that reduce tobacco-related disparities.

2.4.1.2 Participate in Health Communication

Recipients will coordinate with HPCDP staff throughout the duration of the funding period on strategic communication efforts in the recipient’s community. Recipients will leverage the current state resources available, such as the Smokefree Oregon and Place Matters Oregon health communication platforms and brands (SmokefreeOregon.com and PlaceMattersOregon.com).


Recipients will state communication objectives (see Appendix A - Local Program Plan Definitions) in their Local Program Plan that support their proposed strategy(s). Communication activities will be included in their Local Program Plan to describe how Applicants will meet their proposed communication objectives.

2.4.1.3 Participate in Evaluation

Recipients will participate in evaluation activities led by HPCDP staff (or contractors) throughout the duration of the funding period. Such activities include:

• Meet with an evaluator within two months after the award of funds to develop an evaluation plan specific to Recipient’s project(s),

• Collect data and maintain progress documentation throughout the award period,

• Respond to the evaluator’s requests for information; and • Collaborate with the evaluator to develop final reports and

dissemination products that will highlight outcomes of the Recipient’s work.

Recipients will report data to the evaluator on a schedule developed by the Recipient and Evaluator and documented in the evaluation plan.

2.4.1.4 Present to Decision Makers and Elected Bodies

Recipients will share program successes and evaluation results with decision makers, elected bodies, policy makers and partners, including communities disproportionately impacted by tobacco. Throughout the project period, Recipients will submit at least two (2) dissemination products, including but not limited to conference presentations, success stories, earned media coverage, etc. Recipients will inform key audiences about tobacco prevention retail strategies, through presentations and/or formal meetings. Audiences will include at least two (2) of the following decision making bodies: State Legislator, County Commissioners, City Leaders, Tribal Councils, CCO governance bodies.

2.4.1.5 Reporting

Recipients will complete interview progress reports with HPCDP staff five times during the award period on a schedule determined by HPCDP, to document progress toward achieving Local Program Plan milestones. Guidance for preparing for interview reports will be sent to Recipients at least two weeks prior to the interview schedule period.


OHA will work with Recipients to schedule the reporting interview date prior to the interview schedule period. Recipients are required to submit copies of new policies within the reporting period in which they are adopted.

2.4.2 Staffing and Staff Development

2.4.2.1 Staffing

The Recipient will designate qualified program staff to carry out the activities included in the Local Program Plan and participate in communications and evaluation activities as coordinated and conducted by HPCDP. The Recipient will designate a Point of Contact between the Recipient and HPCDP, and will maintain sufficient staff to support regular, consistent communication and coordination with HPCDP. Additionally, if applying as a Consortium, each entity in the Consortium must identify a main Point of Contact and communicate regularly with the Consortium lead and HPCDP. New positions may be established using funds from SPArC Tobacco-free funding. For key staff not identified prior to Application submission, a position description and plan for hiring within six weeks of the Notice of Award must be submitted.

2.4.2.2 Staff Development

Participation is required at HPCDP-sponsored trainings, meetings and conference calls. The Point of Contact for each Recipient (and Consortia representatives) is required to complete all staff development requirements in this funding opportunity. Any staff working 0.5 FTE or more on Local Program Plan activities is required to complete all staff development requirements from this RFGA. Other staff funded through SPArC Tobacco-free that do not meet the above definitions are expected to complete staff development opportunities that are related to their function within the program. HPCDP reserves the right to require SPArC Tobacco-free funded staff to attend any given training that is deemed pertinent to their role, and will negotiate this with the Recipient on a case by case basis. Recipient will ensure staff attendance at the following staff development opportunities: One (1) eLearning module, monthly SPArC Tobacco-free calls, one (1) Grantee and Contractors Meeting and one (1) Place Matters conference. 1. eLearning refers to self-guided learning hosted through the Oregon

Health Authority’s Learning Center or website.


2. SPArC Tobacco-free grantee calls. SPArC Tobacco-free grantee calls include all SPArC Tobacco-free Recipients. They are convened to provide peer support and learning, to share strategies and resources, and to identify training needs. Calls are held monthly and grantees typically meet via phone for approximately one hour each time. Grantees may also choose to meet in-person. If the SPArC Tobacco-free grantees choose to meet in-person, they are responsible for the costs of the gathering including travel, meeting rooms and other logistics. When possible, time will be provided during in-person meetings for SPArC Tobacco-free grantees to gather.

3. Grantees and Contractors Meeting. This meeting will be held in fall

2016. Recipients are required to attend the entire meeting. There will be no registration fee and HPCDP will cover the hotel and meals during the meeting.

4. Place Matters Conference. Place Matters will be held in fall 2016.

Recipients are required to attend the entire meeting.


SECTION 3: PROCUREMENT REQUIREMENTS AND EVALUATION

3.1 MINIMUM REQUIREMENTS To be considered for evaluation, Applicant must meet all of the following minimum qualifications as documented by Applicant’s Application Cover Sheet (Attachment A) and specifically, as follows:

3.1.1 Minimum Applicant Requirements

3.1.1.1 Each Applicant must be an LPHA, RHEC, THA or nonprofit health and social service organization, as defined above. If an LPHA is not the Lead Applicant, an LPHA must be a member of the Consortium.

3.1.1.2 Each Applicant must have a 100% tobacco-free facility policy or have a plan in place to adopt a tobacco-free facility policy by the end of the award period. If applying as a consortium, the Lead Applicant must meet this qualification.

3.1.1.3 Pursuant to OAR 333-010-0320, each Applicant must disclose any and all direct and indirect organizational or business relationships between:

a) the Applicant or any of its subcontractors, including its owners,

parent company or subsidiaries, and b) companies involved in any way in the production, processing,

distribution, promotion, advocacy, sale or use of tobacco and tobacco-related products or on behalf of such entities.

The determination of if Proposer has met these requirements is in the sole discretion of OHA.

3.2 MINIMUM SUBMISSION REQUIREMENTS

3.2.1 Application Format and Quantity

Application should follow the format and reference the sections listed in the Application Content Requirements section. Responses to each section and subsection should be labeled to indicate the item being addressed. Application must describe in detail how requirements of this RFGA will be met and may provide additional related information. Budget information must be submitted in the format suggested in Attachment F – Line Item Budget and Narrative Worksheet. OHA and the Office of Contracts & Procurement (OCP) seek to reduce excessive use of paper, and therefore allow Applications for this RFGA to be submitted using one of the following methods:


o Electronic Application submitted via email as an Adobe® Acrobat® .pdf file attachment, in compliance with Section 3.2.1.1 below; or

o Paper Application submitted in compliance with Section 3.2.1.2 below.

Applications must use 8 ½" x 11" page format using 12 point font size, unreduced, single spaced, one inch margins. Applications should be typed but without extensive art work, unusual printing or other materials not essential to the utility and clarity of the Applications. Each Application must contain a signed original. Applications must address all Application and submission requirements set forth in this RFGA, and must describe how the services will be provided. Applications that merely offer to provide services as stated in this RFGA will be considered non-responsive to this RFGA and will not be considered further. Applicants must meet the requirements for Independent Contractor Status as defined in ORS §§ 316, 656, 657, and 701. Applications will be evaluated on overall quality of content and responsiveness to the purpose and specifications of this RFGA. Only those Applications that include complete information as required by this RFGA will be considered for evaluation.

3.2.1.1 Electronic Application Option

OHA may receive Electronic Applications in accordance with this Section 3.2.1.1. Electronic Applications in response to this RFGA must be in the form of an Adobe® Acrobat® .pdf file containing the Application and all required supporting information and documents. Applicants must submit the Adobe® Acrobat® .pdf scan file attachment containing the Electronic Application to the SPC via email to the SPC at this email address: [email protected] with the message subject line: “ELECTRONIC APPLICATION TO RFGA #4127.”

The signature on the Application Cover Sheet (Attachment A) shall be a scan of an original ink signature. Each Applicant shall retain Applicant’s original signed Application, which the SPC may request to verify the authenticity of the signature on the Application Cover sheet of the Applicant’s Electronic Application. Failure of the authorized representative to sign the Application may subject the Application to rejection by OHA Office of Contracts and Procurement.


Important Notes re Electronic Applications:

The file size of all Electronic Applications in the form of Adobe® Acrobat® .pdf files must not exceed 10 megabytes.

Electronic Application pdf files should not be encrypted or password-protected. OCP strongly recommends that Applicants:

o submit Electronic Applications several days before the Application Due Date, to cover the possibility of email transmission issues or other technical problems; and

o contact the SPC at the phone number listed on the title page of this RFGA to confirm receipt of the email containing Applicant’s Electronic Application immediately after sending the email to the SPC containing that document.

The SPC will attempt to confirm receipt of all Electronic Applications within one business day of receipt at the Issuing Office.

Neither OCP nor OHA are responsible for email transmission issues or other technical problems in the transmission of Electronic Applications, or readability of Adobe® Acrobat® .pdf files attached to Applicant’s Electronic Application.

The Adobe® Acrobat® .pdf file attachments will not be opened by the SPC prior to the Application Due Date and Time.

3.2.1.2 Paper Application Option

Applicant may submit its Applications in paper form pursuant to this Section 3.2.1.2. A representative authorized to bind the Applicant must sign the Application Cover Sheet in ink where indicated. Failure of the authorized representative to sign the Application may subject the Application to rejection by OHA Office of Contracts and Procurement. Paper Applications submitted in response to this RFGA must be in the form of an Application Package containing the original Application and all required supporting information and documents on white paper and one (1) additional copy, and must be contained in a sealed package addressed to the SPC and clearly marked "APPLICATION TO RFGA #4127."

3.2.2 Application Submission Requirements

All Applications will be reviewed for completeness. If complete, Applications will be evaluated on overall quality of content and responsiveness to the purpose and specifications of this RFGA. Only those Applications that include complete information as required by this RFGA will be considered for evaluation. In addition, if Applicant believes any of its Application is exempt from disclosure under Oregon Public Records Law (ORS 192.410 through 192.505), Applicant shall complete and submit the Affidavit of Trade Secret (Attachment B) and a fully redacted version of its Application, clearly identified as the redacted version.


3.2.3 Authorized Representative

A representative authorized to bind the Applicant shall sign the Application. If the Application is submitted electronically, the signature on the Application Cover Sheet (Attachment 1) shall be a scan of an original ink signature. Each Applicant shall retain Applicant’s original signed Application, which the SPC may request to verify the authenticity of the signature on the Application Cover sheet of the Applicant’s Electronic Application.

3.3 PROCUREMENT PROCESS

3.3.1 Public Notice The RFGA, including all Addenda and attachments, is published in the Oregon Procurement Information Network (ORPIN) at http://www.orpin.oregon.gov. RFGA documents will not be mailed to prospective Applicants. OHA shall advertise all Addenda on ORPIN. Prospective Applicant is solely responsible for checking ORPIN to determine whether or not any Addenda have been issued. Addenda are incorporated into the RFGA by this reference.

3.3.2 Questions / Requests for Clarification All inquiries, whether relating to the RFGA process, administration, deadline or method of award, or to the intent or technical aspects of the RFGA must: Be delivered to the SPC via email, facsimile, or hard copy; Reference the RFGA number; Identify Applicant’s name and contact information; Be sent by an authorized representative; Refer to the specific area of the RFGA being questioned (i.e. page, section and paragraph

number); and Be received by the due date and time for Questions/Requests for Clarification identified

in Section 1.2 “Schedule” of this RFGA.

3.3.3 Pre-Application Conference

A pre-Application conference will not be held for this RFGA.

3.3.4 Application Submission Options

Applicant is solely responsible for ensuring its Application is received by the SPC in accordance with the RFGA requirements before Closing. OHA is not responsible for any delays in mail or by common carriers or by transmission errors or delays or mistaken delivery. Application submitted by any means not authorized will be rejected.

http://www.orpin.oregon.gov/


3.3.4.1 Submission through ORPIN

Submission through ORPIN is not allowed for this RFGA.

3.3.4.2 Submission through Mail or Parcel Carrier Application may be submitted through the mail or via parcel carrier, and must be clearly labeled and submitted in a sealed envelope, package or box. The outside of the sealed submission must clearly identify the Applicant’s name and the RFGA number. It must be sent to the attention of the SPC at the address listed on the Cover Page.

3.3.4.3 Submission in Person Application may be hand delivered, and must be clearly labeled and submitted in a sealed envelope, package or box. Application will be accepted, prior to Closing, during OHA’s normal Monday –Friday business hours of 8:00 am to 5:00 pm Pacific Time, except during State of Oregon holidays and other times when OHA is closed. The outside of the sealed submission must clearly identify the Applicant’s name and the RFGA number. It must be delivered to the attention of the SPC at the address listed on the Cover Page.

3.3.5 Application Modification or Withdrawal Any Applicant who wishes to make modifications to an Application already received by OHA shall submit its modification in one of the manners listed in the Application Submission Options section and must denote the specific change(s) to the Application submission. If an Applicant wishes to withdraw a submitted Application, it shall do so prior to Closing. The Applicant shall submit a written notice signed by an authorized representative of its intent to withdraw its Application. The notice must include the RFGA number and be submitted to the SPC.

3.3.6 Application Due Application and all required submittal items must be received by the SPC on or before Closing. Applications received after the Closing will not be accepted. All Application modifications or withdrawals must be completed prior to Closing. Applications received after Closing are considered LATE and will NOT be accepted for evaluation. Late Applications will be returned to the respective Applicant or destroyed.

3.3.7 Application Rejection

OHA may reject an Application for any of the following reasons:


Applicant fails to substantially comply with all prescribed RFGA procedures and requirements, including but not limited to the requirement that Applicant’s authorized representative sign the Application in ink.

Applicant fails to meet the responsibility requirements of ORS 279B.110. Applicant makes any contact regarding this RFGA with State representatives such as

State employees or officials other than the SPC or those the SPC authorizes, or inappropriate contact with the SPC.

Applicant attempts to inappropriately influence a member of the Evaluation Committee.

3.3.8 Opening of Application There will be no public Opening of Applications. Applications received will not be available for inspection until after the evaluation process has been completed and the Notice of Award is issued. However, OHA will record and make available the identity of all Applicants after Opening.

3.4 APPLICATION CONTENT REQUIREMENTS Application must address each of the items listed in this section and all other requirements set forth in this RFGA. Applicant shall describe the activities that will be carried out and the proposed goals and objectives for the project period. An Application that merely offers to complete the activities as stated in this RFGA will be considered non-Responsive to this RFGA and will not be considered further.

3.4.1 Application Cover Sheet (Parts 1 & 2) (Attachment A) Each Applicant must complete Parts 1 and 2 of the Application Cover Sheet and sign Part 1. The Application Cover Sheet must be the top page(s) of the Proposal.

3.4.2 Affidavit of Trade Secret (Attachment B) (if applicable)

If applicable, the Applicant shall complete and submit the Affidavit of Trade Secret and a redacted version of the Application.

3.4.3 Tax Affidavit (Attachment C) The Applicant shall complete and submit the Tax Affidavit. Failure to demonstrate compliance with Oregon Tax Laws may result in a finding of non-responsibility.

3.4.4 Project Narrative (Attachment D) (Total Page Limit: 9 pages) As further described below, Applicants must submit a Project Narrative using Attachment 2 that describes the Applicant’s:

(1) background, capacity and community need; (2) project leadership and key staff; (3) plans to engage partners; (4) strategy selection;


(5) health communication participation; (6) evaluation participation; and (7) plans to present to decision makers and elected bodies.

3.4.4.1 Background, capacity and community need Describes the Applicant’s ability to achieve the selected strategies and evaluation

dissemination.

Describes the tobacco use burden of specific populations addressed through the strategy

selection.

Describes the Applicant’s 100% tobacco-free facility policy or plan that is in place to adopt

such a policy during the award period.

(Recommended length: 1 page)

3.4.4.2 Project leadership and key staff Describes Applicant leadership support for and role in promoting the adoption of tobacco

retail policies. If appropriate, include Consortium member leadership support and role.

Describes existing key staff. If key staff are to be hired, include a position description and

plans for hiring within six weeks of Notice of Award.

(Recommended length: 1.25 pages)

3.4.4.3 Partner Engagement Describes plan to identify partners that play a key role in Applicant’s ability to achieve

proposed strategy(s).

Describes plan to engage and mobilize these partners in achieving proposed strategy(s).


3.4.4.4 Strategy selection States strategy(s) selected to address tobacco in the retail environment and describes how

strategy(s) selected complements, expands or accelerates the existing TPEP work plan; is

achievable in the time of the grant; and, is a “recommended” policy, systems or

environmental change for tobacco prevention in the retail environment. Describes what

SPArC Tobacco-free funds would allow the Applicant to accomplish, including the specific

jurisdiction(s) chosen and data supporting the jurisdiction(s) selection.

Describes how intervention(s) selected addresses tobacco-related disparities. Describes the

intended population to be reached by the strategy.


3.4.4.5 Health Communication participation Describes key messages that would be used in a presentation to decision makers to move a

tobacco retail policy forward.

Describes plan to leverage state communication resources, such as Smokefree Oregon and

Place Matters Oregon brands, to support accomplishment of strategy(s). (Applicants are


required to provide a communication objective and activities for each strategy in the Local

Program Plan.)

(Recommended length: .5 pages)

3.4.4.6 Evaluation participation Describes commitment to participate in evaluation plans developed by HPCDP.

Describes the Applicant’s experience with conducting an evaluation and using the

evaluation results.

(Recommended length: .5 pages)

3.4.4.7 Presentation to Decision Makers and Elected Bodies Describes plan to share program successes with specific policy and decision makers, and

partners.

Describes plan to inform specific policy and decision makers, and partners, about tobacco

prevention retail strategies.

(Recommended length: 1 page) 3.4.4.8 Applicants may include the following in the Project Narrative (Bonus

Section):

Relationship to local CCO(s) and other health system partners • Describes the current relationship between the Applicant and the local CCO(s) and

health system partners. • Describes plan to develop a strengthened partnership with the local CCO(s) and

health systems to jointly pursue sustainable systems change to address tobacco prevention in the retail environment.

Relationship to local American Indian/Alaska Native serving organizations • Describes the current relationship between the Applicant and local American

Indian/Alaska Native serving organizations. • Describes plan to develop a strengthened relationship with local American

Indian/Alaska Native serving organization(s) to jointly pursue sustainable systems change that addresses tobacco prevention in the community.

3.4.5 Local Program Plan (Attachment E) (No Page limit)

The Local Program Plan demonstrates the steps necessary to achieve policy, systems or environmental changes that reduce the influence of tobacco in the retail environment. The Local Program Plan includes: • strategy; • current status; • milestones; • communication objective; and


• activities addressing assessment, partner engagement, decision maker education, public engagement, policy development, policy adoption, and policy implementation.

Applicants must submit a Local Program Plan for each proposed strategy; no more than three strategies per Applicant will be reviewed. Attachment 3 is provided as a Local Program Plan template. Appendix A Local Program Plan Definitions provides definitions of noted categories.

3.4.6 Optional Letters of Support (No Page limit)

Letters of Support are optional, and should demonstrate commitment(s) to support the Applicant’s proposed strategy(s).

3.4.7 Letters of Commitment (No Page limit)

If applying as a Consortium, each entity represented in the Consortium must submit a Letter of Commitment with the Consortium Application. Letters of Commitment should state the specific role of each Consortium entity and describe commitment to participate in the Local Program Plan activities. Letters should be signed by executive leadership and describe how the entities will sustain long-term collaboration. As a reminder, if an LPHA is not the Lead Applicant, an LPHA must be a member of the Consortium.

3.4.8 Line Item Budget and Narrative Worksheet (Attachment F) (No Page limit) Each Applicant must submit a complete Line Item Budget and Narrative Worksheet (Attachment 4) that will not be scored except as part of the Pass-Fail evaluation. Each Applicant must submit an 18-month budget for proposed funding under this RFGA, for the fiscal period January 4, 2016 – June 30, 2017 (see note in Section 1.1), using the required Line Item Budget and Narrative Worksheet (Attachment #4). Applicants must complete all fields, and provide narrative descriptions of the budget line items as applicable. Each Applicant may request between $50,000 and $300,000 for the 18-month budget (see note in Section 1.1). In budgeting funds for meetings and events, Applicants and Recipients should follow the HPCDP Recommended Nutrition Protocols on Healthy Meetings, Conferences and Events, available on HPCDP Connection. (https://partners.health.oregon.gov/partners/HPCDPConnection/Pages/index.aspx Username: HPCDP; Password: Communities12) Grant funds may not be used to purchase nicotine replacement therapy, or to support staff time providing tobacco cessation client services, such as classes, coaching, or counseling. Funding cannot be used for direct services or to support reimbursement models as part of policy implementation. Funding cannot be used to reimburse for any perceived or demonstrated loss of revenue due to not selling tobacco products. Funds may not be used to purchase educational or advocacy media such as paid advertising in newspapers or radio. The Line Item Budget and Narrative Worksheet should include each of the following Budget Categories, as relevant:


Salary List each position funded by the grant on a separate line. For each position, include the job title, annual salary, FTE as a percentage, and the number of months requested for each staff person. The total salary will automatically calculate. Include a narrative for each position briefly describing their primary responsibilities on the grant. Fringe Benefits List, if applicable, fringe benefit amounts for each position on a separate line. The total fringe will automatically calculate. Unless otherwise indicated, it is the general assumption that the “Base” will be the total salary charged to the contract. Equipment Provide a total amount for equipment, as well as a narrative identifying planned purchases and brief rationale. Office furniture, equipment and computer/software upgrades are allowable provided they are reasonable expenditures and relate to the Local Program Plan. Supplies Provide a total amount for supplies. Supplies may include office supplies or meeting supplies. Expenditures for educational materials must be for materials approved by HPCDP. If expenditures are allocated for educational materials, the narrative must include a justification that describes how such materials are related and essential to specific activities listed in the Local Program Plan. Funds may not be used for clinical cessation services, treatment, or medications. Travel In state: Provide a narrative statement describing proposed in-state travel. Include local mileage as well as per diem, lodging and transportation to attend required and requested meetings. Federal per diem rates limit the amount of reimbursement for in-state travel; please see U.S. General Services Administration Per Diem Rates (www.gsa.gov/perdiem). Note: For the Grantees and Contractors Meeting, there will be no registration fee. However, Applicants should include per diem for meals not offered during the meeting, and mileage to Portland for this meeting. For the Place Matters Conference, there is a registration fee of $50.00 per attendee. Applicants should plan to cover hotel and meal costs during the meeting, in addition to other per diem meals and mileage. The conference will be held in Portland. Out of state: Travel to attend out of state events or conferences is permitted if content is applicable to the Local Program Plan. Provide a narrative statement that includes the name of the event or conference, and how the proposed travel relates to the Local Program Plan. Include amounts for per diem, lodging, transportation, registration fees, and any other expenses. Federal per diem rates limit the amount of reimbursement for out of state travel; please see U.S. General Services Administration Per Diem Rates (www.gsa.gov/perdiem).


Other List expenses for items not listed above, such as telephone, rent, copying, printing, postage, and mailing that are directly related to grant activities. Expenses, such as equipment, supplies, indirect rate or cost allocation may not be included in the “Other” category if they are included elsewhere in the budget. Contracts List each proposed subcontracted program activity and the name of the proposed subcontractor (if known) along with the amount of the proposed contract. All activities related to the subcontractor must be clearly specified in the Local Program Plan, and must include: (1) scope of work, including tasks and deliverables; (2) time period of the contract; (3) person in your agency who will supervise or manage the contract; (4) name of the contractor, if known; and (5) what method will be used to select the contractor, such as bids, RFPs, sole-source, etc. Include this information as a narrative submitted with the budget. If applying as a Consortium, the Lead Applicant submits a master budget with additional applicants listed as contractors, as appropriate. A copy of the budget form may be used to provide details about the budget of the additional applicants. Total Direct Costs The total direct cost line will auto-fill on the worksheet. Confirm that the amount calculated is correct. Cost Allocation and Indirect Rate Indicate the cost allocation or indirect rate. The worksheet will auto-fill the total direct costs and multiply the cost allocation rate against the total direct to calculate the total cost allocation amount and total budget request amount. OHA reserves the right to request additional detail on cost allocation or indirect rates. Totals The worksheet will auto-fill the total budget request amount. Confirm that the amount calculated is correct.

3.4.9 Public Record/Confidential or Proprietary Information All Applications are public record and are subject to public inspection after OHA issues the Notice of Award. If an Applicant believes that any portion of its Application contains any information that is a trade secret under ORS Chapter 192.501(2) or otherwise is exempt from disclosure under the Oregon Public Records Law (ORS 192.410 through 192.505), Applicant shall complete and submit the Affidavit of Trade Secret (Attachment B) and a fully redacted version of its Application. Applicant is cautioned that cost information generally is not considered a trade secret under Oregon Public Records Law (ORS 192.410 through 192.505) and identifying the Application, in whole, as exempt from disclosure is not acceptable. OHA advises each Applicant to consult with its own legal counsel regarding disclosure issues.


If Applicant fails to identify the portions of the Application that Applicant claims are exempt from disclosure, Applicant has waived any future claim of non-disclosure of that information.

3.5 EVALUATION PROCESS

3.5.1 Responsiveness and Responsibility Determination Applications received prior to Closing will be reviewed for Responsiveness to all RFGA requirements including compliance with Section 3.1 “Minimum Requirements” and Section 3.4 “Application Content Requirements.” If the Application is unclear, the SPC may request clarification from Applicant. However, clarifications may not be used to rehabilitate a non-Responsive Application. If the SPC finds the Application non-Responsive, the Application may be rejected, however, OHA may waive minor mistakes at the sole discretion of OHA. At any time prior to award, OHA may reject an Applicant found to be not responsive.

3.5.2 Evaluation Criteria Applications meeting the requirements outlined in the Application Content Requirements section will be evaluated by an Evaluation Committee. 3.5.2.1 Pass/Fail Items.

The items listed below will be scored on a pass/fail basis.

Applicant is an LPHA, RHEC, THA, or nonprofit health and social service organization.

All Section 3.4 “Application Content Requirements” documents are present in

Applicant’s application as follows: o Application Cover Sheet (Parts 1 & 2) (Section 3.4.1) (Attachment A) o Affidavit of Trade Secret (Section 3.4.2) (Attachment B)

Note: this document must be present only if applicable. o Tax Affidavit (Section 3.4.3) (Attachment C) o Project Narrative (Section 3.4.4) (Attachment D) o Local Program Plan (Section 3.4.5) (Attachment E) o Letters of Commitment (Section 3.4.7) o Line Item Budget and Narrative Worksheet (Section 3.4.8) (Attachment

F) IMPORTANT NOTE: ALL DOCUMENTS LISTED IN THIS SECTION 3.5.2.1 SHOULD BE CLEARLY LABLED OR ELECTRONICALLY IDENTIFIED USING THE DOCUMENT TITLE AND SECTION NUMBER SPECIFIED IN THIS SECTION TO ENSURE THEY ARE IDENTIFIABLE FOR THE PURPOSE OF PASS/FAIL EVALUATION BY THE SPC.

SPC may request further clarification to assist the Evaluation Committee in gaining additional understanding of Applications. A response to a clarification request must be


to clarify or explain portions of the already submitted Application and may not contain new information not included in the original Application.

3.5.2.2 Project Narrative (Maximum Score: 73 points)

Applicant’s background, capacity and community need (Section 3.4.4.1) (Maximum Score: 9 points): Does the Applicant demonstrate their ability to achieve the selected strategies and

achieve evaluation dissemination?

Does the Applicant describe the tobacco use burden of specific populations

addressed through the strategy selection?

Does the Applicant describe their 100% tobacco-free facility policy or their plan

that is in place to adopt a 100% tobacco-free facility by the end of the award period?

Project Leadership and key staff (Section 3.4.4.2) (Maximum Score: 11 points): Does the Applicant describe adequate leadership support for promoting the adoption

of tobacco retail policies and leadership’s role in adopting such policies?

Does the Applicant adequately describe existing key staff? If key staff are to be

hired, does the Applicant include a brief position description and plans for hiring

within six weeks of Notice of Award?

Partner Engagement (Section 3.4.4.3) (Maximum Score: 12 points): Does the Applicant describe plans to identify partners that play a key role in their

ability to achieve proposed strategy(s)?

Does the Applicant describe plans to engage and mobilize these partners to achieve

proposed strategy(s)?

Strategy selection (Section 3.4.4.4) (Maximum Score: 21 points): Does the Applicant describe how the strategy(s) selected complement, expand or

accelerate the existing TPEP work plan; is achievable in the time of the grant; and,

is a policy, systems or environmental change for tobacco prevention in the retail

environment that is rated as “recommended” in the 2014 Point-of-Sale Strategies: A

Tobacco Control Guide? Does the Applicant adequately describe the justification

for the selected strategy(s) and the jurisdiction chosen?

Does the Applicant adequately describe the intended population most reached by the

strategy?

Health Communication (Section 3.4.4.5) (Maximum Score: 5 points):

Does the Applicant describe appropriate key messages for use in a presentation to

decision makers to move a tobacco retail policy forward?

Does the Applicant adequately describe plans to leverage state communication

resources and framing, such as Smokefree Oregon and Place Matters Oregon

brands, to support accomplishment of their strategy(s)?


Evaluation participation and dissemination (Section 3.4.4.6) (Maximum Score: 6 points): Does the Applicant sufficiently describe commitment to participate in evaluation

plans developed by HPCDP?

Does the Applicant adequately describe experience with conducting an evaluation

and using the evaluation results?

Presentation to Decision Makers and Elected Bodies (Section 3.4.4.7) (Maximum Score: 9 points): Does the Applicant describe plans to share program successes with specific policy

and decision makers, and partners?

Does the Applicant describe a sufficient plan to inform specific policy and decision

makers about tobacco prevention retail strategies?

Bonus Points (Section 3.4.4.8)

Relationship to local CCO(s) and other health system partners (Maximum Score: 2 points): Describes the current relationship between the Applicant and the local CCO(s)

and health system partners.

Describes plan to develop a strengthened partnership with the local CCO(s) and

health systems to jointly pursue sustainable systems change to address tobacco

prevention in the retail environment.

Relationship to local American Indian/Alaska Native serving organizations (Maximum Score: 2 points): Describes the current relationship between the Applicant and local American

Indian/Alaska Native serving organizations.

Describes plan to develop a strengthened relationship with local American

Indian/Alaska Native serving organization(s) to jointly pursue sustainable

systems change that addresses tobacco prevention in the community.

3.5.2.3 Local Program Plan (Maximum Score: 27 points): Applicant is required to submit Local Program Plans for one to three strategies. Points are not dependent on the number of strategies addressed.

Does the Local Program Plan include sufficient milestones to demonstrate progress towards achieving the strategy? Do milestones included demonstrate adequate steps to achieve the strategy? (Maximum Score: 9 points)

Does the Local Program Plan include sufficient communications objectives to support the strategy? (Maximum Score: 2 points)

Does the Local Program Plan include sufficient activities addressing assessment, partner engagement, decision maker education, public engagement, policy


development, policy adoption, and policy implementation to achieve the milestones and strategy selected? (Maximum Score: 9 points)

Does the Local Program Plan describe the current status of the strategy selected? (Maximum Score: 2 points)

Does the Local Program Plan describe collaboration with organizations representing local populations disproportionately impacted by tobacco products? (Maximum Score: 5 points)

3.6 POINT AND SCORE CALCULATIONS

POINTS POSSIBLE

3.5.2.1 Project Narrative 73 3.5.2.2 Local Program Plan 27

TOTAL POINTS POSSIBLE 100

3.7 FINAL SELECTION

Applicant ranking will be determined by the sum of its scores on the Project Narrative and Local Program Plan. After the OHA Evaluation Committee completes the ranking, an OHA Executive Panel will review the ranked list and make the final selection of Recipients and award amounts. In making the final selection, the OHA Executive Panel will consider proposed activities, size of intervention population, population size of the region served, geographic diversity of region served, health burden of the intervention population, likelihood of Applicant’s success in fulfilling plan strategies, and selected interventions that address populations bearing a disproportionate burden of tobacco use and tobacco related health outcomes.


SECTION 4: AWARD AND NEGOTIATION

4.1 AWARD NOTIFICATION PROCESS

4.1.1 Award Consideration

Award(s), if they are made, will be to the responsive Applicant(s) whose Application(s) best addresses the goals and objectives of this RFGA, most accurately and completely fulfill the requirements of the Program, and are deemed by OHA to best meet the program needs as defined in this RFGA. Award, if made, will be to the highest scoring Applications, but OHA reserves the right to make an award to a lower ranked Applicant that advances specific objectives such as providing expanded services in currently underserved areas of the state, or expanding a program to provide services 24 hours per day, 7 days per week.

4.1.2 Notice of Award OHA will notify all Applicants in Writing that OHA intends to award funding to the selected Applicant(s) subject to successful negotiation of any negotiable provisions.

4.2 APPARENT SUCCESSFUL APPLICANT SUBMISSION REQUIREMENTS

4.2.1 Taxpayer Identification Number The apparent successful Applicant shall provide its Taxpayer Identification Number (TIN) and backup withholding status on a completed W-9 form if either of the following applies: When requested by OHA (normally in an intent to award notice), or When the backup withholding status or any other information of Applicant has changed

since the last submitted W-9 form, if any.

OHA will not make any payment until OHA has received a properly completed W-9.

4.2.2 Business Registry If the Applicant selected for award is a non-governmental entity, the Applicant shall be duly authorized by the State of Oregon to transact business in the State of Oregon before executing the Amendment. The selected Applicant shall submit a current Oregon Secretary of State Business registry number (or an explanation if not applicable). All Corporations and other business entities (domestic and foreign) must have a Registered Agent in Oregon. See requirements and exceptions regarding Registered Agents. For more information, see Oregon Business Guide, How to Start a Business in Oregon and Laws and Rules. The titles in this subsection are available at the following Internet site: http://www.filinginoregon.com/index.htm.


4.3 AGREEMENT NEGOTIATION

OHA will enter into negotiations beginning with the highest ranked Applicant(s) selected by OHA for award of funding and continuing down the list of selected Applicants until funds are exhausted. OHA may choose to not award an Agreement. In the event that Agreement negotiations with the selected highest ranked Applicant(s) are not successful within a reasonable time frame, OHA reserves the right to terminate negotiations with the selected highest ranked Applicant(s), and negotiate with the next selected highest ranked Applicant(s) and so on, until successful negotiations are completed, funds are obligated or OHA decides to terminate all negotiations and cancel the solicitation. OHA reserves the right to negotiate the budget and activities proposed by the selected highest ranked Applicant(s). The determination of what constitutes a reasonable time frame for purposes of this paragraph shall be solely at the determination of OHA. This protocol will be followed until Agreements are been signed and funds are obligated. If all Applications are rejected, Applicants will be promptly notified.


SECTION 5: ADDITIONAL INFORMATION

5.1 GOVERNING LAWS AND REGULATIONS This RFGA is governed by the laws of the State of Oregon without regard for principles related to conflicts of law. Venue for any administrative or judicial action relating to this RFGA, evaluation and award is the Circuit Court of Marion County for the State of Oregon; provided, however, if a proceeding must be brought in a federal forum, then it must be brought and conducted solely and exclusively within the United States District Court for the District of Oregon. In no event shall this Section be construed as a waiver by the State of Oregon of any form of defense or immunity, whether sovereign immunity, governmental immunity, immunity based on the eleventh amendment to the Constitution of the United States or otherwise, to or from any Claim or from the jurisdiction of any court.

5.2 OWNERSHIP/PERMISSION TO USE MATERIALS All Applications submitted in response to this RFGA become the Property of OHA. By submitting an Application in response to this RFGA, Applicant grants the State a non-exclusive, perpetual, irrevocable, royalty-free license for the rights to copy, distribute, display, prepare derivative works of and transmit the Application solely for the purpose of evaluating the Application, negotiating an Agreement, if awarded to Applicant, or as otherwise needed to administer the RFGA process, and to fulfill obligations under Oregon Public Records Law (ORS 192.410 through 192.505). Applications, including supporting materials, will not be returned to Applicant unless the Application is submitted late.

5.3 CANCELLATION OF RFGA; REJECTION OF APPLICATIONS; NO DAMAGES. OHA may reject any or all Applications in-whole or in-part, or may cancel this RFGA at any time when the rejection or cancellation is in the best interest of the State or OHA, as determined by OHA. Neither the State nor OHA is liable to any Applicant for any loss or expense caused by or resulting from the delay, suspension, or cancellation of the RFGA, award, or rejection of any Application.

5.4 COST OF SUBMITTING AN APPLICATION Applicant shall pay all the costs in submitting its Application, including, but not limited to, the costs to prepare and submit the Application, costs of samples and other supporting materials, costs to participate in demonstrations, or costs associated with protests.

5.5 CHANGES/MODIFICATION AND CLARIFICATIONS When appropriate, OHA will issue revisions, substitutions, or clarifications as addenda to this RFGA. Changes/modifications to the RFGA shall be recognized only if in the form of written addenda issued by OHA and posted on ORPIN Site.


5.6 RESERVATION OF OHA RIGHTS

OHA reserves all rights regarding this RFGA, including, without limitation, upon its determination and at its sole discretion that it is in its best interests to do so, the right to:

Amend or cancel this RFGA without liability; Reject any and all Applications in whole or in part received by reason of this RFGA; Waive any minor informality as determined by OHA; Seek clarification of any and all Applications; Reject any Application that fails to substantially comply, in OHA’s determination, with all

prescribed solicitation procedures and requirements; Negotiate the statement of work or any other requirement applicable to a Recipient

described in this RFGA, including but not limited to the rates and budgets; Amend or extend the term of any Agreement that is issued as a result of this RFGA; Engage Recipient by selection or procurement for different or additional services

independent of this RFGA process and any contracts/agreements entered into pursuant hereto;

Enter into direct negotiations to execute an Agreement with a responsive Applicant, in the event that the Applicant is the sole Applicant to this RFGA and OHA determines that the Applicant satisfies the minimum RFGA requirements;

Reject any Offer upon a determination by OHA that such Offer may impair the integrity of the procurement process or the appropriate performance by any Recipient pursuant thereto.

5.7 AWARD NOTICE

The apparent successful Applicant(s) shall be notified in writing and OHA will set the timelines for Agreement negotiation.

5.8 MODIFICATION OR WITHDRAWAL

5.8.1 Modifications. An Applicant may modify its Application in writing prior to the closing. An Applicant must prepare and submit any modification to its Offer to OHA in accordance with Paragraph 5.5, above. Any modification must include the Applicant's statement that the modification amends and supersedes the prior Application. The Applicant must mark the submitted modification “Application Modification RFGA Number 4127“, and be addressed to the attention of the SPC.

5.8.2 Withdrawals.

An Applicant may withdraw its Application by Written notice submitted on the Applicant's letterhead, Signed by an authorized representative of the Applicant, delivered to the SPC in person or in the same manner as set forth in Paragraph


5.5, above. The Applicant must mark the written request to withdraw “Application Withdrawal to RFGA Number 4127.”

5.9 RELEASE OF INFORMATION

No information shall be given to any Applicant (or any other individual) relative to their standing with other Applicants during the RFGA process.

5.10 LIST OF ATTACHMENTS AND APPENDICES ATTACHMENTS

ATTACHMENT A - APPLICATION COVER SHEET (PARTS 1 & 2) ATTACHMENT B - AFFIDAVIT OF TRADE SECRET (SECTION 3.4.2)

NOTE: THIS DOCUMENT MUST BE PRESENT ONLY IF APPLICABLE.

ATTACHMENT C - TAX AFFIDAVIT (SECTION 3.4.3) ATTACHMENT D - PROJECT NARRATIVE (SECTION 3.4.4) ATTACHMENT E - LOCAL PROGRAM PLAN (SECTION 3.4.5) LETTERS OF COMMITMENT (SECTION 3.4.7) ATTACHMENT F - LINE ITEM BUDGET AND NARRATIVE WORKSHEET (SECTION 3.4.8)

APPENDICES Appendix A - LIST OF LOCAL PROGRAM PLAN DEFINITIONS Appendix B - TOBACCO PREVENTION AND EDUCATION (TPEP)

PROGRAM ELEMENT (PE) DESCRIPTIONS Appendix C - FORM AMENDMENTS (LPHA and Tribal) Appendix D - FORM AGREEMENT (for new agreements resulting from this RFGA)


ATTACHMENT A: APPLICATION COVER SHEET Part 1: Applicant Information

(RFGA OHA-4127-15) Applicant Name: For non-governmental organizations, check one box:

Applicant is a: publicly held company or privately held company. Primary Contact Person: Title: Address: City, State, Zip Telephone: Fax: E-mail Address: Name and title of the person(s) authorized to represent the Applicant in any negotiations and sign any Personal Services Contract that may result: Name: Title: By signing this page and submitting an Application, the Authorized Representative certifies that the following statements are true:

1. No attempt has been made or will be made by the Applicant to induce any other person or organization to submit or not submit an Application.

2. Applicant does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, sex, disability, sexual orientation or national origin, nor has Applicant or will Applicant discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is a minority, women or emerging small business enterprise certified under ORS 200.055.

3. Information and costs included in this Application shall remain valid for 90 days after the Application due date or until a Grant Agreement is approved, whichever comes first.

4. The statements contained in this Application are true and complete to the best of the Applicant’s knowledge and Applicant accepts as a condition of the Grant Agreement, the obligation to comply with the applicable state and federal requirements, policies, standards, and regulations. The undersigned recognizes that this is a public document and open to public inspection.

5. The Applicant, by submitting an Application in response to this Request for Grant Applications, certifies that it understands that any statement or representation contained in, or attached to, its Application, and any statement, representation, or application the Applicant may submit under any Grant Agreement OHA may award under this Request for Grant Applications, that constitutes a “claim” (as defined by the Oregon False Claims Act, ORS 180.750(1)), is subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

6. The Applicant acknowledges receipt of all addenda issued under this RFGA. 7. If the Applicant is awarded a Grant Agreement as a result of this RFGA, the Applicant will be

required to complete, and will be bound by, a Grant Agreement as attached to this RFGA and found on the ORPIN website. At the time of signing the Grant Agreement with OHA the Applicant will be required to provide their Federal Employer Identification Number (FEIN) or Social Security Number (SSN) as applicable.


8. Pursuant to ORS 279B.060(2)(c), the Applicant, if awarded a Grant Agreement, agrees to meet the highest standards prevalent in the industry or business most closely involved in providing the appropriate goods or services as stated in the scope of work.

9. The Applicant if awarded a Grant Agreement, certifies and agrees that Applicant will not finance the same activities in the Program Description under more than one Grant and will not supplant or duplicate existing local, state or federal funding for any activities within the Program Description of the Grant Agreement.

10. Applicant understands and agrees that Grants resulting from this RFGA will be issued in the form of Amendments to the OHA, Public Health Financial Assistance Agreements, Program Element 13: Tobacco Prevention and Education Program (TPEP) and Program Element 16: Tribal Tobacco Prevention and Education Program (Tribal TPEP). For RHEC’s or private non-profit entities, Grants resulting from the RFGA may be issued as an amendment to an existing Contract or Agreement, or may be issued as a separate Grant Agreement.

Signature: Date:

(Authorized to Bind Applicant)

*** THIS PAGE SHOULD BE THE TOP PAGE OF THE APPLICATION ***


ATTACHMENT A: APPLICATION COVER SHEET Part 2: Applicant’s Statement of Compliance with

Section 3.1.1 - Minimum Requirements (RFGA OHA-4127-15)

Applicant Name: Instructions:

Check one response (Yes or No) for each minimum qualification listed below to verify Applicant meets the criteria under Section 3.1.1 - Minimum Requirements.

Provide documentation for Applicant’s Responses by completing the attached Supporting

Information re: Applicant’s Statement of Compliance with Section 3.1.1 - Minimum Requirements re: RFGA 4127 below.

Section 3.1.1.1: Is Applicant a Local Public Health Authority (LPHA), Tribal health Agency (THA),

Regional Health Equity Coalition (RHEC), or nonprofit health and social service organization, as defined above?

Yes No

If the Lead Applicant is not an LPHA, is an LPHA a member of the Consortium?

Yes No

Section 3.1.1.2: Does Applicant have a 100% tobacco-free facility policy or a plan in place to adopt a

100% tobacco-free facility policy by the end of the award period?

Yes No Section 3.1.1.3: Has Applicant disclosed in the attached forms any and all direct and indirect

organizational or business relationships between:

the Applicant or any of its subcontractors, including its owners, parent company or subsidiaries, and

companies involved in any way in the production, processing, distribution, promotion, advocacy, sale or use of tobacco and tobacco-related products or on behalf of such entities.

Yes No

*** ATTACHMENT A SHOULD BE THE TOP PAGES OF THE APPLICATION ***


ATTACHMENT A: APPLICATION COVER SHEET Part 2 (continued): Supporting Information re:

Applicant’s Statement of Compliance with Section 3.1.1 Minimum Requirements

(RFGA OHA-4127-15)

Applicant Name:

Program Contact Information (Section 3.1.1.1 Minimum Requirements)

Instructions: Provide the information requested below for program contact information, disclosure of tobacco relationships, and tobacco free campus policy.

Applicant Name (Lead Applicant Name)

Name:

Additional Applicant Name (If applying as a Consortium)

Name:

Applicant’s Main Point of Contact

Name:

Phone:

E-mail:

Other Key Personnel (add additional personnel if

necessary) Name:

Applicant’s Principal Administrator or Executive Director (or equivalent capacity in the organization)

Name:

Phone:

E-mail:

Applicant’s Assistant/Deputy Administrator(s) or Executive Director(s) (if applying as a Consortium. Add additional if necessary)

Name:

Phone:

E-mail:


Description of Tobacco Free Campus Policy (Section 3.1.1.2 Minimum Requirements)

Describe the current policy of the Lead Applicant regarding tobacco use on the property.

If the Lead Applicant does not have a 100% tobacco-free policy in place, does the Lead Applicant have plans in place to adopt a tobacco-free facility policy by the end of the award period? Yes No

Describe the current policy of the other Applicants in the Consortium (if applicable) regarding tobacco use on the property. If Consortium members do not have 100% tobacco-free policies in place, do all Consortium members have plans in place to adopt a tobacco-free facility policy by the end of the award period? Yes No

Disclosure of Tobacco Relationships (Section 3.1.1.3 Minimum Requirements)

Complete the following form, pursuant to Oregon Administrative Rules 333-010-0320, which requires disclosure of any and all direct and indirect organizational or business relationships between the Applicant or its subcontractors, including its owners, parent company or subsidiaries, and companies involved in any way in the production, processing, distribution, promotion, advocacy, sale or use of tobacco and tobacco-related products or on behalf of such entities. Does the Applicant have any direct or indirect relationship with tobacco-related companies, as described above? Yes No If yes, please disclose any such relationships:

*** ATTACHMENT A SHOULD BE THE TOP PAGES OF THE APPLICATION ***


ATTACHMENT B – AFFIDAVIT OF TRADE SECRET (RFGA OHA-4127-15)

_____________________________________________ (Affiant), being first duly sworn under oath, and representing [insert Applicant Name] (hereafter “Applicant”), hereby deposes and swears or affirms under penalty of perjury that: 1. I am an employee of the Applicant, I have knowledge of the Request for Grant Applications

referenced herein, and I have full authority from the Applicant to submit this affidavit and accept the responsibilities stated herein.

2. I am aware that the Applicant has submitted an Application, dated on or about [insert date]

(the “Application”), to the State of Oregon (State) in response to Request for Grant Applications OHA-4127-15, for Strategies for Policy And enviRonmental Change, Tobacco-free (SPArC Tobacco-Free), and I am familiar with the contents of the RFGP and Application.

3. I have read and am familiar with the provisions of Oregon’s Public Records Law, Oregon

Revised Statutes (“ORS”) 192.410 through 192.505, and the Uniform Trade Secrets Act as adopted by the State of Oregon, which is set forth in ORS 646.461 through ORS 646.475. I understand that the Application is a public record held by a public body and is subject to disclosure under the Oregon Public Records Law unless specifically exempt from disclosure under that law.

4. I have reviewed the information contained in the Application. The Applicant believes the

information listed in Exhibit A is exempt from public disclosure (collectively, the “Exempt Information”), which is incorporated herein by this reference. It is my opinion that the Exempt Information constitutes “Trade Secrets” under either the Oregon Public Records Law or the Uniform Trade Secrets Act as adopted in Oregon because that information is either:

A. A formula, plan, pattern, process, tool, mechanism, compound, procedure,

production data, or compilation of information that:

i is not patented,

ii is known only to certain individuals within the Applicant’s organization and that is used in a business the Applicant conducts,

iii has actual or potential commercial value, and

iv gives its user an opportunity to obtain a business advantage over competitors

who do not know or use it.

or

B. Information, including a drawing, cost data, customer list, formula, pattern, compilation, program, device, method, technique or process that:


i Derives independent economic value, actual or potential, from not being generally known to the public or to other persons who can obtain economic value from its disclosure or use; and

ii Is the subject of efforts by the Applicant that are reasonable under the

circumstances to maintain its secrecy.

I understand that disclosure of the information referenced in Exhibit A may depend on official or judicial determinations made in accordance with the Public Records Law. ________________________________________________ Affiant’s Signature State of ___________) ) ss: County of ________) Signed and sworn to before me on ___________ (date) by ______________________ (Affiant’s name). ________________________________________________ Notary Signature Notary Public for the State of: _________________ My Commission Expires: _________


EXHIBIT A to Affidavit of Trade Secret

Applicant identifies the following information as exempt from public disclosure:


ATTACHMENT E – AFFIDAVIT OF COMPLIANCE WITH TAX LAWS RFGP OHA-4118-15

____________________________________ (Affiant), being first duly sworn under oath, and representing [insert legal name of firm] (hereafter “Offeror”), hereby deposes and swears or affirms under penalty of perjury that: 1. I am an authorized agent of the Offeror, and I have full authority from the Offeror to

submit this affidavit and accept the responsibilities stated herein.

2. I have knowledge regarding Offeror’s payment of taxes, and to the best of my knowledge, Offeror is not in violation of any Oregon tax laws, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.

3. Offeror shall provide written notice to Agency within two business days of any change to

the Offeror’s status of tax law compliance. ________________________________________________ Affiant’s Signature State of __________) ) ss: County of ________) Signed and sworn to before me on ___________ (date) by ______________________ (Affiant’s name). ________________________________________________ Notary Signature Notary Public for the State of: _________________ My Commission Expires: ____________________


ATTACHMENT D: PROJECT NARRATIVE (RFGA OHA-4127-15)

(Page Limit: 9 Pages Total)

Applicant Name:

Applicant’s background, capacity and community need

(Recommended page length: 1 page)

Project Leadership and key staff

(Recommended page length: 1.25 pages)

Partner Engagement


Strategy selection


Health Communication participation

(Recommended page length: .5 pages)

Evaluation participation

(Recommended page length: .5 pages)

Presentation to Decision Makers and Elected Bodies

(Recommended page length: 1 page)

Optional: Relationship to local CCO(s) and other health system partners

Optional: Relationship to local American Indian/Alaska Native serving organizations


ATTACHMENT E: LOCAL PROGRAM PLAN

(RFGA OHA-4127-15)

SPArC Tobacco-Free

Local Program Plan Form

Applicant:

Strategy:

Current status:

Milestones: Anticipated

Completion

Date:

Communication Objective(s):

Activities Communication-Related Activities

Assessment: Partner Engagement:

Policy development and adoption: Decision Maker Education:

Policy implementation and maintenance: Public Engagement:


ATTACHMENT F: LINE ITEM BUDGET AND NARRATIVE WORKSHEET (RFGA OHA-4127-15)


Appendix A: LOCAL PROGRAM PLAN DEFINITIONS The Local Program Plan describes planned efforts to accomplish specific objectives. Program Plan Template:

Strategy: Current status: Milestones: Anticipated

Completion Date:

Communication Objective(s):

Activities Communication-Related Activities

Assessment : Partner Engagement:

Policy development and adoption: Decision Maker Education:

Policy implementation and maintenance: Public Engagement:

Local Program Plan Element Definitions: Strategy: Plan strategies are outcomes for which Applicants anticipate spending the majority of time and resources. Applicants should pick strategies based on local needs assessments, community will for policy change, and what will complement policies or community conditions that are already in place. Every strategy should emphasize a policy outcome that promotes tobacco-free environments and communities, reduces the influence of tobacco in the retail environment, and encourages tobacco users to quit and keeps youth from starting. To reduce tobacco-related disparities, plans should focus on policies that will best reach populations affected by disparities. Milestones: Milestones demonstrate tangible progress toward policy change and include target achievement dates. Milestones are a progress measurement tool for evaluation. If target achievement dates are missed, Applicants are expected to adjust timelines and future activities, in consultation with HPCDP, to ensure that the desired strategy outcome is achieved by its target date. Milestones are more than simply accounts of completed activities. For example, having a coalition meeting is not a milestone; however, documenting the establishment of a commissioner’s public support for a policy strategy is a milestone. Sample milestones include:

Commissioner voices support at public hearing Policy draft is created by a committee or workgroup and presented to appropriate

decision makers


Fee structure for tobacco retail license is developed Communication Objective: An effective communication objective is achievable in a meaningful timeframe, influences the opinion, attitude or behavior of the target audience(s) and is measureable. A sample communication objective for the Smokefree Oregon prevention campaign is:

Increase awareness of the predatory nature of the tobacco industry towards children, minorities and people of low socioeconomic status among Oregonians with more than a high-school education aged 25-65.

Activities: Activities are the specific, measurable actions that will be completed to mobilize the community toward accomplishing strategies. Specific activities should be chosen that will best help achieve milestones. The field of tobacco prevention has ample guidance from Centers for Disease Prevention and Control (CDC) Best Practices on which activities to employ. Local Program Plans should include the combination of activities that make sense for the proposal.


Appendix B: TOBACCO PREVENTION AND EDUCATION (TPEP)

PROGRAM ELEMENT (PE) DESCRIPTIONS

Program Element #13: Tobacco Prevention and Education Program (TPEP)

1. Description. Funds provided under the Financial Assistance Agreement for this Program

Element may only be used, in accordance with and subject to the requirements and limitations

set forth below, to implement Tobacco Prevention and Education Program (TPEP) activities in

the following areas:

a. Facilitation of Community Partnerships: Accomplish movement toward tobacco-free

communities through a coalition or other group dedicated to the pursuit of agreed upon

tobacco control objectives. Community partners should include non-governmental

entities as well as community leaders.

b. Creating Tobacco-Free Environments: Promote the adoption of tobacco policies,

including voluntary policies in schools, workplaces and public places. Enforce local

tobacco-free ordinances and the Oregon Indoor Clean Air Act (OICAA.)

c. Countering Pro-Tobacco Influences: Reduce the promotion of tobacco on storefronts,

in gas stations, at community events and playgrounds in the community. Counter

tobacco industry advertising and promotion. Reduce youth access to tobacco products,

including working with retailers toward voluntary policies.

d. Promoting Quitting Among Adults and Youth: Integrate the promotion of the Oregon

Tobacco Quit Line into other tobacco control activities.

e. Enforcement: Assist with the enforcement of statewide tobacco control laws, including

minors’ access to tobacco and restrictions on smoking through formal agreements with

OHA, Public Health Division.

f. Reducing the Burden of Tobacco-Related Chronic Disease: Address tobacco use

reduction strategies in the broader context of chronic diseases and other risk factors for

tobacco-related chronic diseases including cancer, asthma, cardiovascular disease,

diabetes, arthritis, and stroke.

2. Procedural and Operational Requirements. By accepting and using the financial assistance

funds provided by OHA under this Financial Assistance Agreement and this Program Element,

LPHA agrees to conduct TPEP activities in accordance with the following requirements:

a. LPHA must have on file with OHA an approved Local Program Plan by no later than

June 30th of each year. OHA will supply the required format and current service data

for use in completing the plan. LPHA shall implement its TPEP activities in accordance

with its approved Local Program Plan. Modifications to this plan may only be made

with OHA approval.


b. LPHA must assure that its local tobacco program is staffed at the appropriate level,

depending on its level of funding, as specified in the award of funds for this Program

Element.

c. LPHA must use the funds awarded to LPHA under this Agreement for this Program

Element in accordance with its budget as approved by OHA and attached to this

Program Element as Attachment 1 and incorporated herein by this reference.

Modifications to the budget may only be made with OHA approval. Funds awarded for

this Program Element may not be used for treatment, other disease control programs, or

other health-related efforts not devoted to tobacco prevention and education.

d. LPHA must attend all TPEP meetings reasonably required by OHA.

e. LPHA must comply with OHA’s TPEP Program Guidelines and Policies.

f. LPHA must coordinate its TPEP activities and collaborate with other entities receiving

TPEP funds or providing TPEP services.

g. In the event of any omission from, or conflict or inconsistency between, the provisions

of the Local Program Plan on file at OHA, the Budget set forth in Attachment 1 and the

provisions of the Agreement and this Program Element, the provisions of the

Agreement and this Program Element shall control.

3. Reporting Requirements. LPHA must submit Local Program Plan reports on a quarterly

schedule to be determined by OHA. The reports must include, at a minimum, LPHA’s progress

during the quarter towards completing activities described in its Local Program Plan. Upon

request by OHA, LPHA must also submit reports that detail quantifiable outcomes of activities

and data accumulated from community-based assessments of tobacco use.

4. Performance Measures. LPHAs that complete fewer than 75% of the planned activities in its

Local Program Plan for two consecutive calendar quarters in one state fiscal year shall not be

eligible to receive funding under this Program Element during the next state fiscal year.


Attachment 1 to Program Element 13 (TPEP)

Budget

[Reserved]


Program Element # 16: Tribal Tobacco Prevention and Education Program (Tribal TPEP)

1. Description. Funds provided under the Financial Assistance Agreement for this Program Element

may only be used, in accordance with and subject to the requirements and limitations set forth

below, to implement Tobacco Prevention and Education Program (TPEP) activities in the following

areas:

a. Facilitation of Community Partnerships: Accomplish movement toward commercial

tobacco-free tribal communities through a coalition or other group dedicated to the pursuit of

agreed upon tobacco control objectives. Community partners should include non-

governmental entities as well as community leaders.

b. Creating Tobacco-Free Environments: Promote the adoption of tobacco policies, including

voluntary policies in schools, workplaces and public places. Enforce local tobacco-free

ordinances and resolutions.

c. Countering Pro-Tobacco Influences: Reduce the promotion of tobacco on storefronts, in gas

stations, at community events and playgrounds in the community. Counter tobacco industry

advertising and promotion. Reduce youth access to tobacco products, including working

with retailers toward voluntary policies.

d. Promoting Quitting Among Adults and Youth: Integrate the promotion of the Oregon

Tobacco Quit Line and tribal cessation services into other tobacco control activities.

e. Reducing the Burden of Tobacco-Related and Other Chronic Diseases: Address tobacco use

reduction strategies in the broader context of chronic diseases and other risk factors for

tobacco-related chronic diseases including cancer, asthma, arthritis, diabetes, cardiovascular

disease, and stroke.

2. Procedural and Operational Requirements.

a. Tribe must have on file with OHA an approved Tribal Program Plan no later than June 30 of

each year. OHA will supply the required format and current service data for use in

completing the plan. Tribe shall implement its TPEP activities in accordance with its

approved Tribal Program Plan. Modifications to this plan may only be made with OHA

approval.

b. Tribe must assure that its local tobacco program is staffed at the appropriate level, depending

on its level of funding, as specified in the award of funds for this Program Element.

c. Tribe must use the funds awarded to Tribe for this Program Element in accordance with its

Budget as approved by OHA and attached as Attachment 1 to this Program Element and

incorporated herein by this reference. Modifications to the budget may only be made with

OHA approval. Funds awarded for this Program Element may not be used for medical

treatment, delivery of cessation services, or other health-related efforts not devoted to

tobacco prevention and education or other chronic diseases as determined by OHA.

d. Tribe must attend all TPEP meetings, as reasonably required by OHA.


e. Tribe must comply with OHA’s TPEP Program Guidelines and Policies.

f. Tribe must coordinate its TPEP activities and collaborate with other entities receiving TPEP

funds or providing TPEP services.

g. In the event of any omission from, or conflict or inconsistency between, the provisions of the

Tribal Program Plan on file at OHA, the Budget set forth in Attachment 1 and the provisions

of the Agreement and this Program Element, the provisions of the Agreement and this

Program Element shall control.

3. Reporting Requirements. Tribe must submit quarterly Tribal Program Plan reports on a schedule

to be determined by OHA. The reports must include, at a minimum, Tribe’s progress during the

quarter in completing activities described in the Tribal Program Plan. Tribe must submit the

following upon request by OHA: outcomes reports that detail quantifiable outcomes of activities and

data accumulated from community-based assessments.

4. Performance Measures. A Tribe who completes fewer than 75% of the planned activities in its

Tribal Program Plan during the first six months of the fiscal year will be required to submit a revised

Tribal Program Plan that ensures the Tribe will meet program requirements. The revised Tribal

Program Plan will be subject to OHA’s approval.


Attachment 1 to Program Element 16 (Tribal TPEP)

Budget

[Reserved]


Appendix C: FORM AMENDMENTS

Agreement #

[AMENDMENT NUMBER] AMENDMENT TO OREGON HEALTH AUTHORITY

2015-2017 INTERGOVERNMENTAL AGREEMENT FOR THE

FINANCING OF PUBLIC HEALTH SERVICES


alternate formats such as Braille, large print, audio recordings, Web-based

communications and other electronic formats. To request an alternate format, please

send an e-mail to [email protected] or call 503-378-3486 (voice)

or 503-378-3523 (TTY) to arrange for the alternative format.

This [Amendment Number] Amendment to Oregon Health Authority 2015-2017 Intergovernmental

Agreement for the Financing of Public Health Services, effective July 1, 2015 (as amended the

“Agreement”), is between the State of Oregon acting by and through its Oregon Health Authority

(“OHA”) and [County/LPHA Name], acting by and through its [Department Name] (“LPHA”), the

entity designated, pursuant to ORS 431.375(2), as the Local Public Health Authority for

[County/LPHA Name].

Note: this form amendment would apply to a standard,

two-party (County/OHA) LPH-FAA agreement and is provided as an example only.

RECITALS

WHEREAS, OHA and LPHA wish to…

e.g. […modify the Financial Assistance Award set forth in Exhibit C of the Agreement.]

[…replace PE ## with the updated version attached to this amendment]

NOW, THEREFORE, in consideration of the premises, covenants and agreements contained

herein and other good and valuable consideration, the receipt and sufficiency of which is hereby

acknowledged, the parties hereto agree as follows

AGREEMENT

1. e.g. Section 1 of Exhibit C entitled “Financial Assistance Award” of the Agreement is hereby

superseded and replaced in its entirety by Exhibit 1 attached hereto and incorporated herein by

this reference. Exhibit 1 must be read in conjunction with Section 4 of Exhibit C, entitled

“Explanation of Financial Assistance Award” of the Agreement.

2. e.g. PE ## “PE title” is hereby [superseded and replaced] or [added] by PE ## “PE title” set

forth in Exhibit 2 “Program Element Descriptions” to this Amendment and hereby

incorporated into the Agreement by this reference.


3. LPHA represents and warrants to OHA that the representations and warranties of LPHA set

forth in Section 2 of Exhibit E of the Agreement are true and correct on the date hereof with the

same effect as if made on the date hereof.

4. Capitalized words and phrases used but not defined herein shall have the meanings ascribed

thereto in the Agreement.

5. Except as amended hereby, all terms and conditions of the Agreement remain in full force and

effect.

6. This Amendment may be executed in any number of counterparts, all of which when taken

together shall constitute one agreement binding on all parties, notwithstanding that all parties

are not signatories to the same counterpart. Each copy of this Amendment so executed shall

constitute an original.

7. This Amendment becomes effective on the date of the last signature below.

IN WITNESS WHEREOF, the parties hereto have executed this Amendment as of the dates set

forth below their respective signatures.

8. Signatures.

STATE OF OREGON ACTING BY AND THROUGH ITS OREGON HEALTH AUTHORITY (OHA)

By:

Name: [Name of OHA Authorized Representative]

Title: [Title]

Date:

[County/LPHA Name] acting by and through its [Department Name] (LPHA)

By:

Name:

Title:

Date:

DEPARTMENT OF JUSTICE – APPROVED FOR LEGAL SUFFICIENCY

Approved by [AAG Name] on [Approval Date]. Copy of approval on file at Office of Contracts and

Procurement (OC&P.)

OFFICE OF CONTRACTS & PROCUREMENT

By:

Name: [Contract Specialist Name]

Title: Contract Specialist

Date:


EXHIBIT 1

FINANCIAL ASSISTANCE AWARD

EXHIBIT 2

PROGRAM ELEMENT DESCRIPTIONS





[email protected] or call 503-378-3486 (voice) or 503-378-3523 (TTY) to

arrange for the alternative format.

Agreement #

[AMENDMENT NUMBER] AMENDMENT TO

2015-2017 TRIBAL FINANCIAL ASSISTANCE AGREEMENT

FOR THE FINANCING OF TRIBAL HEALTH SERVICES

This [Amendment Number] Amendment to Oregon Health Authority 2015-2017 Tribal Financial

Assistance Agreement, effective July 1, 2015 (as amended the “Agreement”), is between the State of Oregon,

acting by and through its Oregon Health Authority, hereinafter referred to as "OHA" and [Name of Tribe]

hereinafter referred to as "Tribe."

RECITALS

WHEREAS, OHA and Tribe wish to e.g. modify the set of Program Element Descriptions set forth in

Exhibit B of the Agreement,

WHEREAS, OHA and Tribe wish to e.g. add an Exhibit to the current set of Exhibits set forth in the

Agreement,

WHEREAS, OHA and Tribe wish to e.g. modify the Financial Assistance Award set forth in Exhibit C

of the Agreement.

AGREEMENT

NOW, THEREFORE, in consideration of the premises, covenants and agreements contained herein

and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the

parties hereto agree as follows:

Examples only:

1. Section 2 “Agreement in its Entirety” is amended to add…

2. Exhibit B “Program Element Descriptions” is amended to e.g. add…

3. Section 1 of Exhibit C entitled “Financial Assistance Award” of the Agreement is hereby superseded

and replaced in its entirety by Attachment XX attached hereto and incorporated herein by this

reference. Attachment XX must be read in conjunction with Section 4 of Exhibit C, entitled

“Explanation of Financial Assistance Award” of the Agreement.

4. Exhibit F “Information required by CFR Subtitle B with guidance at 2 CFR Part 200” e.g. is

amended…


5. Tribe represents and warrants to OHA that the representations and warranties of Tribe set forth in

Section 4. of Exhibit D of the Agreement are true and correct on the date hereof with the same effect

as if made on the date hereof. OHA represents and warrants to Tribe that the representations and

warranties of OHA set forth in Section 4. of Exhibit D of the Agreement are true and correct on the

date hereof with the same effect as if made on the date hereof.

6. Capitalized words and phrases used but not defined herein shall have the meanings ascribed thereto in

the Agreement.

7. Except as amended hereby, all terms and conditions of the Agreement remain in full force and effect.

8. This Amendment may be executed in any number of counterparts, all of which when taken together

shall constitute one agreement binding on all parties, notwithstanding that all parties are not

signatories to the same counterpart. Each copy of this Amendment so executed shall constitute an

original.

THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK


IN WITNESS WHEREOF, the parties hereto have executed this Amendment as of the dates set forth

below their respective signatures.

9. Signatures.

State of Oregon Acting by and through its Oregon Health Authority (OHA)

By:

Name:

Title:

Date:

[Name of Tribe] (Tribe)

By:

Name:

Title:

Date:

Department of Justice – Approved for legal sufficiency

Approved by _________________ on ___________________. Copy of emailed approval on file at OCP.

REVIEWED:

OHA, Public Health Administration

Reviewed by:

Name:

Title:

Date:

Office of Contracts and Procurement

By:

Name:

Title:

Date:

Attachment XX to Amendment #«Amdt_» to Tribal Agreement #«KT»

PROGRAM ELEMENT DESCRIPTIONS


FINANCIAL ASSISTANCE AWARD


EXHIBIT F

Information required by CFR Subtitle B with guidance at 2 CFR Part 200


Appendix D: FORM AGREEMENT

Grant Agreement Number [#]

STATE OF OREGON

GRANT AGREEMENT




[email protected] or call 503-378-3486 (voice) or 503-378-3523 (TTY) to

arrange for the alternative format.

This Agreement is between the State of Oregon, acting by and through its Oregon Health Authority,

hereinafter referred to as “OHA,” and

Recipient Legal Entity Name

d.b.a. Facility or Assumed Name

Address

Address

Telephone: (required)

Facsimile: (optional)

E-mail address: (required)

Recipient’s home page URL, if applicable (optional)

hereinafter referred to as “Recipient.”

The Program to be supported under this Agreement relates principally to OHA’s

Name of OHA Office, Program, etc.

Address

Address

Agreement Administrator: (Insert Name) or delegate

Telephone: (Insert)

Facsimile: (Insert)

E-mail address: (Insert)


1. Effective Date and Duration.

This Agreement shall become effective on the date this Agreement has been fully executed by

every party and, when required, approved by Department of Justice or on [insert start date],

whichever date is later. Unless extended or terminated earlier in accordance with its terms, this

Agreement shall expire on [insert end date]. Agreement termination shall not extinguish or

prejudice OHA’s right to enforce this Agreement with respect to any default by Recipient that

has not been cured.

2. Agreement Documents.

a. This Agreement consists of this document and includes the following listed exhibits

which are incorporated into this Agreement:

(1) Exhibit A, Part 1: Program Description

(2) Exhibit A, Part 2: Payment and Financial Reporting

(3) Exhibit A, Part 3: Special Terms and Conditions

(4) Exhibit B: Standard Terms and Conditions

(5) Exhibit C: Insurance Requirements

(6) Exhibit D: Required Federal Terms and Conditions

(7) Exhibit E: Required Subcontractor Provisions (optional – may be

removed)

(8) Exhibit F: Information Required by 2 CFR Subtitle B with guidance at

2 CFR Part 200

There are no other Agreement documents unless specifically referenced and

incorporated in this Agreement.

b. In the event of a conflict between two or more of the documents comprising this

Agreement, the language in the document with the highest precedence shall control. The

documents comprising this Agreement shall be in the following descending order of

precedence: this Agreement less all exhibits, Exhibits D, A, B, C, E and F.

3. Grant Disbursement Generally.

The maximum not-to-exceed amount payable to Recipient under this Agreement, which

includes any allowable expenses, is [insert dollar amount]. OHA will not disburse grant to

Recipient in excess of the not-to-exceed amount and will not disburse grant until this

Agreement has been signed by all parties. OHA will disburse the grant to Recipient as

described in Exhibit A.

4. Vendor or Sub-Recipient Determination.

In accordance with the State Controller’s Oregon Accounting Manual, policy 30.40.00.102,

OHA’s determination is that:

Recipient is a sub-recipient Recipient is a vendor Not applicable

Catalog of Federal Domestic Assistance (CFDA) #(s) of federal funds to be paid through

this Agreement: [CFDA#]


5. Recipient Data and Certification.

a. Recipient Information. Recipient shall provide the information set forth below.

Please print or type the following information

Optional: If Recipient is self-insured for any of the Insurance Requirements specified in Exhibit C of

this Agreement, Recipient may so indicate by: (i) writing “Self-Insured” on the appropriate line(s);

and (ii) submitting a certificate of insurance as required in Exhibit C, section 9.

Recipient Name (exactly as filed with the

IRS):

Street

address:

City, state,

zip code:

Email

address:

Telephone: ( ) Facsimile: ( )

Is Recipient a nonresident alien, as defined in 26 USC § 7701(b)(1)?

(Check one box): YES NO

Recipient Proof of Insurance, as required by Exhibit C, Section 7:

All insurance listed must be in effect at the time of provision of services under this Agreement.

Professional Liability Insurance Company: ______________________________________________

Policy #: ________________________________________ Expiration Date: _________________

Commercial General Liability Insurance Company: _______________________________________


Automobile Liability Insurance Company: ______________________________________________


Workers’ Compensation: Does Recipient have any subject workers, as defined in ORS 656.027?

(Check one box): YES NO If YES, provide the following information:

Workers’ Compensation Insurance Company: ____________________________________________


Business Designation: (Check one box):

Professional Corporation Nonprofit Corporation Limited

Partnership

Limited Liability Company Limited Liability Partnership Sole

Proprietorship

Corporation Partnership Other


The above information must be provided prior to Agreement execution. Recipient shall provide proof

of Insurance upon request by OHA or OHA designee.

b. Certification. The Recipient acknowledges that the Oregon False Claims Act, ORS

180.750 to 180.785, applies to any “claim” (as defined by ORS 180.750) that is

made by (or caused by) the Recipient and that pertains to this Agreement or to the

project for which the grant activities are being performed. The Recipient certifies

that no claim described in the previous sentence is or will be a “false claim” (as

defined by ORS 180.750) or an act prohibited by ORS 180.755. Recipient further

acknowledges that in addition to the remedies under this Agreement, if it makes (or

causes to be made) a false claim or performs (or causes to be performed) an act

prohibited under the Oregon False Claims Act, the Oregon Attorney General may

enforce the liabilities and penalties provided by the Oregon False Claims Act

against the Recipient. Without limiting the generality of the foregoing, by signature

on this Agreement, the Recipient hereby certifies that:

(1) Under penalty of perjury the undersigned is authorized to act on behalf of

Recipient and that Recipient is, to the best of the undersigned’s knowledge, not

in violation of any Oregon Tax Laws. For purposes of this certification, “Oregon

Tax Laws” means a state tax imposed by ORS 320.005 to 320.150 and 403.200

to 403.250 and ORS chapters 118, 314, 316, 317, 318, 321 and 323 and the

elderly rental assistance program under ORS 310.630 to 310.706 and local taxes

administered by the Department of Revenue under ORS 305.620;

(2) The information shown in this Section 5., Recipient Data and Certification, is

Recipient’s true, accurate and correct information;

(3) To the best of the undersigned’s knowledge, Recipient has not discriminated

against and will not discriminate against minority, women or emerging small

business enterprises certified under ORS 200.055 in obtaining any required

subcontracts;

(4) Recipient and Recipient’s employees and agents are not included on the list

titled “Specially Designated Nationals and Blocked Persons” maintained by the

Office of Foreign Assets Control of the United States Department of the

Treasury and currently found at:

http://www.treas.gov/offices/enforcement/ofac/sdn/t11sdn.pdf;

(5) Recipient is not listed on the non-procurement portion of the General Service

Administration’s “List of Parties Excluded from Federal procurement or Non-

procurement Programs” found at: https://www.sam.gov/portal/public/SAM/;

(6) Recipient is not subject to backup withholding because:

https://www.sam.gov/portal/public/SAM/


RECIPIENT, BY EXECUTION OF THIS AGREEMENT, HEREBY ACKNOWLEDGES

THAT RECIPIENT HAS READ THIS AGREEMENT, UNDERSTANDS IT, AND AGREES

TO BE BOUND BY ITS TERMS AND CONDITIONS.

6. Signatures. This Agreement and any subsequent amendments may be executed in several

counterparts, all of which when taken together shall constitute one agreement binding on all parties,

notwithstanding that all parties are not signatories to the same counterpart. Each copy of the Agreement and

any amendments so executed shall constitute an original.

Recipient Name

By:

State of Oregon acting by and through its Oregon Health Authority

By:

Approved for Legal Sufficiency:

Office of Contracts and Procurement:

(a) Recipient is exempt from backup withholding;

(b) Recipient has not been notified by the IRS that Recipient is subject to

backup withholding as a result of a failure to report all interest or

dividends; or

(c) The IRS has notified Recipient that Recipient is no longer subject to

backup withholding.

c. Recipient is required to provide its Federal Employer Identification Number (FEIN) or

Social Security Number (SSN) as applicable to OHA. By Recipient’s signature on this

Agreement, Recipient hereby certifies that the FEIN or SSN provided to OHA is true

and accurate. If this information changes, Recipient is also required to provide OHA

with the new FEIN or SSN within 10 days.


EXHIBIT A

Part 1

Program Description

EXHIBIT A

Part 2

Payment and Financial Reporting

EXHIBIT A

Part 3

Special Terms and Conditions

1. HIPAA Compliance. The health care component of OHA is a Covered Entity and must

comply with the Health Insurance Portability and Accountability Act and the federal

regulations implementing the Act (collectively referred to as HIPAA). Contractor is a Business

Associate of the health care component of OHA and therefore must comply with OAR 943-

014-0400 through OAR 943-014-0465 and the Business Associate requirements set forth in 45

CFR 164.502 and 164.504.

Contractor shall be liable to OHA and shall indemnify OHA for any and all costs incurred

by OHA, including, but not limited to, costs of issuing any notices required by HIPAA,

HITECH or any other applicable law, as a result of Contractor’s “Breach of Unsecured

Protected Health Information.”

a. Consultation and Testing. If Contractor reasonably believes that the Contractor’s or OHA’s

data transactions system or other application of HIPAA privacy or security compliance

policy may result in a violation of HIPAA requirements, Contractor shall promptly consult

the OHA Information Security Office. Contractor or OHA may initiate a request for testing

of HIPAA transaction requirements, subject to available resources and the OHA testing

schedule.

b. Data Transactions Systems. If Contractor intends to exchange electronic data transactions

with a health care component of OHA in connection with claims or encounter data,

eligibility or enrollment information, authorizations or other electronic transaction,

Contractor shall execute an Electronic Data Interchange (EDI) Trading Partner Agreement

with OHA and shall comply with OHA EDI Rules set forth in OAR 943-120-0110 through

943-120-0160.


EXHIBIT B

Standard Terms and Conditions

1. Governing Law, Consent to Jurisdiction.

2. Compliance with Law.

Recipient shall comply with all federal, state and local laws, regulations, executive orders and

ordinances applicable to this Agreement or to the implementation of the project. Without

limiting the generality of the foregoing, Recipient expressly agrees to comply with (i) Title VI

of Civil Rights Act of 1964; (ii) Title V and Section 504 of the Rehabilitation Act of 1973; (iii)

the Americans with Disabilities Act of 1990 and ORS 659A.142; (iv) all regulations and

administrative rules established pursuant to the foregoing laws; and (v) all other applicable

requirements of federal and state civil rights and rehabilitation statutes, rules and regulations.

This Section shall survive expiration or termination of this Agreement.

3. Independent Parties; Conflict of Interest.

a. Recipient is not an officer, employee, or agent of the State of Oregon as those terms are

used in ORS 30.265 or otherwise.

b. If Recipient is currently performing work for the State of Oregon or the federal

government, Recipient by signature to this Agreement, represents and warrants that

Recipient’s participation in this Agreement creates no potential or actual conflict of

interest as defined by ORS Chapter 244 and that no statutes, rules or regulations of the

State of Oregon or federal agency for which Recipient currently performs work would

prohibit Recipient’s participation under this Agreement. If disbursement under this

Agreement is to be charged against federal funds, Recipient certifies that it is not

currently employed by the federal government.

This Agreement shall be governed by and construed in accordance with the laws of the State of Oregon

without regard to principles of conflicts of law. Any claim, action, suit or proceeding (collectively,

“Claim”) between OHA or any other agency or department of the State of Oregon, or both, and

Recipient that arises from or relates to this Agreement shall be brought and conducted solely and

exclusively within the Circuit Court of Marion County for the State of Oregon; provided, however, if a

Claim must be brought in a federal forum, then it shall be brought and conducted solely and

exclusively within the United States District Court for the District of Oregon. In no event shall this

Section be construed as a waiver by the State of Oregon of the jurisdiction of any court or of any form

of defense to or immunity from any Claim, whether sovereign immunity, governmental immunity,

immunity based on the eleventh amendment to the Constitution of the United States or otherwise. Each

party hereby consents to the exclusive jurisdiction of such court, waives any objection to venue, and

waives any claim that such forum is an inconvenient forum. This Section shall survive expiration or

termination of this Agreement.


4. Grant Funds; Payments.

a. Recipient is not entitled to compensation under this Agreement by any other agency or

department of the State of Oregon. Recipient understands and agrees that OHA’s

participation in this Agreement is contingent on OHA receiving appropriations,

limitations, allotments or other expenditure authority sufficient to allow OHA, in the

exercise of its reasonable administrative discretion, to participate in this Agreement.

b. Disbursement Method. Disbursements under this Agreement will be made by Electronic

Funds Transfer (EFT) and shall be processed in accordance with the provisions of OAR

407-120-0100 through 407-120-0380 or OAR 410-120-1260 through OAR 410-120-

1460, as applicable, and any other OHA Oregon Administrative Rules that are program-

specific to the billings and payments. Upon request, Recipient must provide its

taxpayer identification number (TIN) and other necessary banking information to

receive EFT payment. Recipient must maintain at its own expense a single financial

institution or authorized payment agent capable of receiving and processing EFT using

the Automated Clearing House (ACH) transfer method. The most current designation

and EFT information will be used for all disbursements under this Agreement.

Recipient must provide this designation and information on a form provided by OHA.

In the event that EFT information changes or the Recipient elects to designate a

different financial institution for the receipt of any payment made using EFT

procedures, Recipient will provide the changed information or designation to OHA on

an OHA-approved form.

5. Recovery of Overpayments.

Any funds disbursed to Recipient under this Agreement that are expended in violation or

contravention of one or more of the provisions of this Agreement “Misexpended Funds” or

that remain unexpended on the earlier of termination or expiration of this Agreement must

be returned to OHA. Recipient shall return all Misexpended Funds to OHA promptly after

OHA’s written demand and no later than 15 days after OHA’s written demand. Recipient

shall return all Unexpended Funds to OHA within 14 days after the earlier of termination or

expiration of this Agreement. OHA, in its sole discretion, may recover Misexpended or

Unexpended Funds by withholding from payments due to Recipient such amounts, over

such periods of time, as are necessary to recover the amount of the overpayment. Prior to

withholding, if Recipient objects to the withholding or the amount proposed to be withheld,

Recipient shall notify OHA that it wishes to engage in dispute resolution in accordance

with Section 13 of this Exhibit.

6. Reserved.

7. Indemnity.

RECIPIENT SHALL DEFEND (SUBJECT TO ORS CHAPTER 180) SAVE, HOLD

HARMLESS, AND INDEMNIFY THE STATE OF OREGON AND OHA AND THEIR

OFFICERS, EMPLOYEES AND AGENTS FROM AND AGAINST ALL CLAIMS, SUITS,

ACTIONS, LOSSES, DAMAGES, LIABILITIES, COSTS AND EXPENSES OF ANY

NATURE WHATSOEVER, INCLUDING ATTORNEYS FEES, RESULTING FROM,

ARISING OUT OF, OR RELATING TO THE ACTIVITIES OF RECIPIENT OR ITS

OFFICERS, EMPLOYEES, SUBCONTRACTORS, OR AGENTS UNDER THIS

AGREEMENT.


THIS SECTION SHALL SURVIVE EXPIRATION OR TERMINATION OF THIS

AGREEMENT.

8. Default; Remedies; Termination.

a. Default by Recipient. Recipient shall be in default under this Agreement if:

(1) Recipient institutes or has instituted against it insolvency, receivership or

bankruptcy proceedings, makes an assignment for the benefit of creditors, or

ceases doing business on a regular basis; or

(2) Recipient no longer holds a license or certificate that is required for Recipient to

perform its obligations under the Agreement and Recipient has not obtained

such license or certificate within 14 calendar days after OHA’s notice or such

longer period as OHA may specify in such notice; or

(3) Recipient commits any material breach or default of any covenant, warranty,

obligation or agreement under this Agreement, fails to perform any obligation

under this Agreement within the time specified herein or any extension thereof,

or so fails to pursue performance of any obligation as to endanger Recipient’s

performance under this Agreement in accordance with its terms, and such

breach, default or failure is not cured within 14 calendar days after OHA’s

notice, or such longer period as OHA may specify in such notice.

b. OHA’s Remedies for Recipient’s Default. In the event Recipient is in default under

Section 8.a., OHA may, at its option, pursue any or all of the remedies available to it

under this Agreement and at law or in equity, including, but not limited to:

(1) termination of this Agreement under Section 8.e.(2);

(2) withholding all or part of monies not yet disbursed by OHA to Recipient;

(3) initiation of an action or proceeding for damages, specific performance, or

declaratory or injunctive relief; or

(4) exercise of its right of recovery of overpayments under Section 5. of this Exhibit

B.

These remedies are cumulative to the extent the remedies are not inconsistent, and OHA

may pursue any remedy or remedies singly, collectively, successively or in any order

whatsoever. If a court determines that Recipient was not in default under Section 8.a.,

then Recipient shall be entitled to the same remedies as if this Agreement was

terminated pursuant to Section 8.e.(1).

c. Default by OHA. OHA shall be in default under this Agreement if OHA commits any

material breach or default of any covenant, warranty, or obligation under this

Agreement, and such breach or default is not cured within 30 calendar days after

Recipient’s notice or such longer period as Recipient may specify in such notice.

d. Recipient’s Remedies for OHA’s Default. In the event OHA terminates the Agreement

under Section 8.e.(1), or in the event OHA is in default under Section 8.c. and whether

or not Recipient elects to exercise its right to terminate the Agreement under Section

8.e.(3), Recipient’s sole monetary remedy will be a claim for unpaid invoices or for

reimbursement or disbursement of funds authorized by this Agreement but not yet


invoiced. In no event shall OHA be liable to Recipient for any expenses related to

termination of this Agreement or for anticipated profits or loss.

e. Termination.

(1) OHA’s Right to Terminate at its Discretion. At its sole discretion, OHA may

terminate this Agreement:

(a) For its convenience upon 30 days’ prior written notice by OHA to

Recipient;

(b) Immediately upon written notice if OHA fails to receive funding,

appropriations, limitations, allotments or other expenditure authority at

levels sufficient to continue supporting the program; or

(c) Immediately upon written notice if federal or state laws, regulations, or

guidelines are modified or interpreted in such a way that OHA’s support

of the program under this Agreement is prohibited or OHA is prohibited

from paying for such support from the planned funding source.

(d) Immediately upon written notice to Recipient if there is a threat to the

health, safety, or welfare of any person receiving funds or benefitting

from services under this Agreement “OHA Client”, including any

Medicaid Eligible Individual, under its care.

(2) OHA’s Right to Terminate for Cause. In addition to any other rights and

remedies OHA may have under this Agreement, OHA may terminate this

Agreement immediately upon written notice to Recipient, or at such later date as

OHA may establish in such notice if Recipient is in default under Section 8.a.

(3) Recipient’s Right to Terminate for Cause. Recipient may terminate this

Agreement upon 30 days written notice to OHA or at such later date as

Recipient may establish in such notice, if OHA is in default under Section 8.c.

and OHA fails to cure such default within 30 calendar days after OHA receives

Recipient’s notice or such longer period as Recipient may specify in such notice.

(4) Mutual Termination. The Agreement may be terminated immediately upon

mutual written consent of the parties or at such other time as the parties may

agree in the written consent.

(5) Return of Property. Upon termination of this Agreement for any reason

whatsoever, Recipient shall immediately deliver to OHA all of OHA’s property

that is in the possession or under the control of Recipient at that time. This

Section 8.e.(5) survives the expiration or termination of this Agreement.

(6) Effect of Termination. Upon receiving a notice of termination of this Agreement

or upon issuing a notice of termination to OHA, Recipient shall immediately cease

all activities under this Agreement unless, in a notice issued by OHA, OHA

expressly directs otherwise.

9. Insurance.

Recipient shall maintain insurance as set forth in Exhibit C, attached hereto.


10. Records Maintenance, Access.

Recipient shall maintain all financial records relating to this Agreement in accordance with

generally accepted accounting principles. In addition, Recipient shall maintain any other

records, books, documents, papers, plans, records of shipments and payments and writings of

Recipient, whether in paper, electronic or other form, that are pertinent to this Agreement, in

such a manner as to clearly document Recipient’s performance. All financial records, other

records, books, documents, papers, plans, records of shipments and payments and writings of

Recipient whether in paper, electronic or other form, that are pertinent to this Agreement, are

collectively referred to as “Records.” Recipient acknowledges and agrees that OHA and the

Secretary of State’s Office and the federal government and their duly authorized representatives

shall have access to all Records to perform examinations and audits and make excerpts and

transcripts. Recipient shall retain and keep accessible all Records for the longest of:

a. Six years following final payment and termination of this Agreement;

b. The period as may be required by applicable law, including the records retention

schedules set forth in OAR Chapter 166; or

c. Until the conclusion of any audit, controversy or litigation arising out of or related to

this Agreement.

11. Information Privacy/Security/Access.

If this Agreement requires or allows Recipient or, when allowed, its subcontractor(s), to

have access to or use of any OHA computer system or other OHA Information Asset for

which OHA imposes security requirements, and OHA grants Recipient or its

subcontractor(s) access to such OHA Information Assets or Network and Information

Systems, Recipient shall comply and require all subcontractor(s) to which such access has

been granted to comply with OAR 943-014-0300 through OAR 943-014-0320, as such

rules may be revised from time to time. For purposes of this Section, “Information Asset”

and “Network and Information System” have the meaning set forth in OAR 943-014-0305,

as such rule may be revised from time to time.

12. Assignment of Agreement, Successors in Interest.

a. Recipient shall not assign or transfer its interest in this Agreement without prior written

consent of OHA. Any such assignment or transfer, if approved, is subject to such

conditions and provisions required by OHA. No approval by OHA of any assignment

or transfer of interest shall be deemed to create any obligation of OHA in addition to

those set forth in this Agreement.

b. The provisions of this Agreement shall be binding upon and inure to the benefit of the

parties, their respective successors, and permitted assigns.

13. Resolution of Disputes.

The parties shall attempt in good faith to resolve any dispute arising out of this Agreement.

In addition, the parties may agree to utilize a jointly selected mediator or arbitrator (for non-

binding arbitration) to resolve the dispute short of litigation. This Section shall survive

expiration or termination of this Agreement.


14. Subcontracts.

Recipient shall not enter into any subcontracts for any part of the program supported by this

Agreement without OHA’s prior written consent. In addition to any other provisions OHA

may require, Recipient shall include in any permitted subcontract under this Agreement

provisions to ensure that OHA will receive the benefit of subcontractor activity(ies) as if the

subcontractor were the Recipient with respect to Sections 1, 2, 3, 6, 7, 9, 10, 11, 12, 14, 15, and

16 of this Exhibit B. OHA’s consent to any subcontract shall not relieve Recipient of any of its

duties or obligations under this Agreement.

15. No Third Party Beneficiaries.

OHA and Recipient are the only parties to this Agreement and are the only parties entitled to

enforce its terms. Nothing in this Agreement gives, is intended to give, or shall be construed to

give or provide any benefit or right, whether directly, indirectly or otherwise, to third persons

any greater than the rights and benefits enjoyed by the general public unless such third persons

are individually identified by name herein and expressly described as intended beneficiaries of

the terms of this Agreement. This Section shall survive expiration or termination of this

Agreement.

16. Severability.

The parties agree that if any term or provision of this Agreement is declared by a court of

competent jurisdiction to be illegal or in conflict with any law, the validity of the remaining

terms and provisions shall not be affected, and the rights and obligations of the parties shall be

construed and enforced as if the Agreement did not contain the particular term or provision

held to be invalid. This Section shall survive expiration or termination of this Agreement.

17. Notice.

OHA: Office of Contracts & Procurement

250 Winter St. NE, Room 306

Salem, OR 97301

Telephone: 503-945-5818

Facsimile: 503-378-4324

This Section shall survive expiration or termination of this Agreement.

Except as otherwise expressly provided in this Agreement, any communications between the parties

hereto or notices to be given hereunder shall be given in writing by personal delivery, facsimile, e-

mail, or mailing the same, postage prepaid to Recipient or OHA at the address or number set forth in

this Agreement, or to such other addresses or numbers as either party may indicate pursuant to this

Section. Any communication or notice so addressed and mailed by regular mail shall be deemed

received and effective five days after the date of mailing. Any communication or notice delivered by e-

mail shall be deemed received and effective five days after the date of e-mailing. Any communication

or notice delivered by facsimile shall be deemed received and effective on the day the transmitting

machine generates a receipt of the successful transmission, if transmission was during normal business

hours of the Recipient, or on the next business day if transmission was outside normal business hours

of the Recipient. Notwithstanding the foregoing, to be effective against the other party, any notice

transmitted by facsimile must be confirmed by telephone notice to the other party. Any communication

or notice given by personal delivery shall be deemed effective when actually delivered to the

addressee.


18. Headings.

The headings and captions to sections of this Agreement have been inserted for identification

and reference purposes only and shall not be used to construe the meaning or to interpret this

Agreement.

19. Amendments; Waiver; Consent.

OHA may amend this Agreement to the extent provided herein, the solicitation document, if

any from which this Agreement arose, and to the extent permitted by applicable statutes and

administrative rules. No amendment, waiver, or other consent under this Agreement shall bind

either party unless it is in writing and signed by both parties and when required, the Department

of Justice. Such amendment, waiver, or consent shall be effective only in the specific instance

and for the specific purpose given. The failure of either party to enforce any provision of this

Agreement shall not constitute a waiver by that party of that or any other provision. This

Section shall survive the expiration or termination of this Agreement.

20. Merger Clause.

This Agreement constitutes the entire agreement between the parties on the subject matter

hereof. There are no understandings, agreements, or representations, oral or written, not

specified herein, regarding this Agreement.


EXHIBIT C

Insurance Requirements

Required Insurance: Recipient shall obtain at Recipient’s expense the insurance specified in this Exhibit C

and shall maintain it in full force and at its own expense throughout the duration of this Agreement.

Recipient shall obtain the following insurance from insurance companies or entities that are authorized to

transact the business of insurance and issue coverage in State and that are acceptable to OHA.

1. Workers Compensation: All employers, including Recipient, that employ subject workers, as

defined in ORS 656.027, shall comply with ORS 656.017 and shall provide workers' compensation

insurance coverage for those workers, unless they meet the requirement for an exemption under

ORS 656.126(2). Recipient shall require and ensure that each of its subcontractors complies with

these requirements.

2. Professional Liability: (amount(s) to be determined)

3. Commercial General Liability: (amount(s) to be determined)

4. Automobile Liability Insurance: (amount(s) to be determined)

5. Additional Insured.

The Commercial General Liability insurance and Automobile Liability insurance required

under this Agreement shall include the State of Oregon, its officers, employees and agents

as Additional Insureds but only with respect to Recipient’s activities to be performed under

this Agreement. Coverage shall be primary and non-contributory with any other insurance

and self-insurance.

6. Notice of Cancellation or Change.

There shall be no cancellation, material change, potential exhaustion of aggregate limits or

non-renewal of insurance coverage(s) without 60 days’ written notice from this Recipient

or its insurer(s) to OHA. Any failure to comply with the reporting provisions of this clause

shall constitute a material breach of Agreement and shall be grounds for immediate

termination of this Agreement by OHA.

7. Proof of Insurance.

Recipient shall provide to OHA information requested in Data Certification for all required

insurance before any activities are performed under this Agreement. Recipient shall pay for

all deductibles, self-insured retention and self-insurance, if any.

8. “Tail” Coverage.

If any of the required liability insurance is on a “claims made” basis, Recipient shall

maintain either “tail” coverage or continuous “claims made” liability coverage, provided

the effective date of the continuous “claims made” coverage is on or before the effective

date of this Agreement, for a minimum of 24 months following the later of: (i) Recipient’s

completion and OHA’s acceptance of all activities under this Agreement, or, (ii) The

expiration of all warranty periods provided under this Agreement. Notwithstanding the

foregoing 24-month requirement, if Recipient elects to maintain “tail” coverage and if the

maximum time period “tail” coverage reasonably available in the marketplace is less than

the 24-month period described above, then Recipient shall maintain “tail” coverage for the


maximum time period that “tail” coverage is reasonably available in the marketplace for the

coverage required under this Agreement. Recipient shall provide to OHA, upon OHA’s

request, certification of the coverage required under this Section 8.

[Optional] Self-Insurance [only if applicable].

Recipient may fulfill its insurance obligations herein through a program of self insurance,

provided that Recipient’s self insurance program complies with all applicable laws, and

provides insurance coverage equivalent in both type and level of coverage to that required

in this Exhibit C. Notwithstanding Section 7. of this Exhibit C, Recipient shall furnish an

acceptable insurance certificate to OHA for any insurance coverage required by this

Agreement that is fulfilled through self-insurance.


EXHIBIT D

Required Federal Terms and Conditions

General Applicability and Compliance. Unless exempt under 45 Part 87 for Faith-Based Organizations

(Federal Register, July 16, 2004, Volume 69, #136), or other federal provisions, Recipient shall comply and,

as indicated, cause all subcontractors to comply with the following federal requirements to the extent that

they are applicable to this Agreement, to Recipient, or to the grant activities, or to any combination of the

foregoing. For purposes of this Agreement, all references to federal and state laws are references to federal

and state laws as they may be amended from time to time.

1. Miscellaneous Federal Provisions. Recipient shall comply and require all subcontractors to comply with all federal laws,

regulations, and executive orders applicable to the Agreement or to the delivery of grant

activities. Without limiting the generality of the foregoing, Recipient expressly agrees to

comply and require all subcontractors to comply with the following laws, regulations and

executive orders to the extent they are applicable to the Agreement: (a) Title VI and VII of

the Civil Rights Act of 1964, as amended, (b) Sections 503 and 504 of the Rehabilitation

Act of 1973, as amended, (c) the Americans with Disabilities Act of 1990, as amended, (d)

Executive Order 11246, as amended, (e) the Health Insurance Portability and

Accountability Act of 1996, as amended, (f) the Age Discrimination in Employment Act of

1967, as amended, and the Age Discrimination Act of 1975, as amended, (g) the Vietnam

Era Veterans’ Readjustment Assistance Act of 1974, as amended, (h) all regulations and

administrative rules established pursuant to the foregoing laws, (i) all other applicable

requirements of federal civil rights and rehabilitation statutes, rules and regulations, and (j)

all federal laws requiring reporting of OHA Client abuse. These laws, regulations and

executive orders are incorporated by reference herein to the extent that they are applicable

to the Agreement and required by law to be so incorporated. No federal funds may be used

to provide grant activities in violation of 42 U.S.C. 14402.

2. Equal Employment Opportunity. If this Agreement, including amendments, is for more than $10,000, then Recipient shall

comply and require all subcontractors to comply with Executive Order 11246, entitled

“Equal Employment Opportunity,” as amended by Executive Order 11375, and as

supplemented in Department of Labor regulations (41 CFR Part 60).

3. Clean Air, Clean Water, EPA Regulations. If this Agreement, including amendments, exceeds $100,000 then Recipient shall comply

and require all subcontractors to comply with all applicable standards, orders, or

requirements issued under Section 306 of the Clean Air Act (42 U.S.C. 7606), the Federal

Water Pollution Control Act as amended (commonly known as the Clean Water Act) (33

U.S.C. 1251 to 1387), specifically including, but not limited to Section 508 (33 U.S.C.

1368), Executive Order 11738, and Environmental Protection Agency regulations (2 CFR

Part 1532), which prohibit the use under non-exempt Federal contracts, grants or loans of

facilities included on the EPA List of Violating Facilities. Violations shall be reported to

OHA, United States Department of Health and Human Services and the appropriate

Regional Office of the Environmental Protection Agency. Recipient shall include and

require all subcontractors to include in all contracts with subcontractors receiving more than

$100,000, language requiring the subcontractor to comply with the federal laws identified

in this Section.


4. Energy Efficiency. Recipient shall comply and require all subcontractors to comply with applicable mandatory

standards and policies relating to energy efficiency that are contained in the Oregon energy

conservation plan issued in compliance with the Energy Policy and Conservation Act 42

U.S.C. 6201 et. seq. (Pub. L. 94-163).

5. Truth in Lobbying. By signing this Agreement, the Recipient certifies, to the best of the

Recipient’s knowledge and belief that:

a. No federal appropriated funds have been paid or will be paid, by or on behalf of

Recipient, to any person for influencing or attempting to influence an officer or

employee of an agency, a Member of Congress, an officer or employee of

Congress, or an employee of a Member of Congress in connection with the

awarding of any federal contract, the making of any federal grant, the making of

any federal loan, the entering into of any cooperative agreement, and the extension,

continuation, renewal, amendment or modification of any federal contract, grant,

loan or cooperative agreement.

b. If any funds other than federal appropriated funds have been paid or will be paid to

any person for influencing or attempting to influence an officer or employee of any

agency, a Member of Congress, an officer or employee of Congress, or an

employee of a Member of Congress in connection with this federal contract, grant,

loan or cooperative agreement, the Recipient shall complete and submit Standard

Form LLL, “Disclosure Form to Report Lobbying” in accordance with its

instructions.

c. The Recipient shall require that the language of this certification be included in the

award documents for all subawards at all tiers (including subcontracts, subgrants,

and contracts under grants, loans, and cooperative agreements) and that all

subrecipients and subcontractors shall certify and disclose accordingly.

d. This certification is a material representation of fact upon which reliance was

placed when this Agreement was made or entered into. Submission of this

certification is a prerequisite for making or entering into this Agreement imposed

by 31 U.S.C. 1352. Any person who fails to file the required certification shall be

subject to a civil penalty of not less than $10,000 and not more than $100,000 for

each such failure.

e. No part of any federal funds paid to Recipient under this Agreement shall be used

other than for normal and recognized executive legislative relationships, for

publicity or propaganda purposes, for the preparation, distribution, or use of any kit,

pamphlet, booklet, publication, electronic communication, radio, television, or

video presentation designed to support or defeat the enactment of legislation before

the United States Congress or any State or local legislature itself, or designed to

support or defeat any proposed or pending regulation, administrative action, or

order issued by the executive branch of any State or local government itself.

f. No part of any federal funds paid to Recipient under this Agreement shall be used

to pay the salary or expenses of any grant or contract recipient, or agent acting for

such recipient, related to any activity designed to influence the enactment of

legislation, appropriations, regulation, administrative action, or Executive order

proposed or pending before the United States Congress or any State government,

State legislature or local legislature or legislative body, other than for normal and

recognized executive-legislative relationships or participation by an agency or


officer of a State, local or tribal government in policymaking and administrative

processes within the executive branch of that government.

g. The prohibitions in subsections (e) and (f) of this Section shall include any activity

to advocate or promote any proposed, pending or future Federal, State or local tax

increase, or any proposed, pending, or future requirement or restriction an any legal

consumer product, including its sale or marketing, including but not limited to the

advocacy or promotion of gun control.

h. No part of any federal funds paid to Recipient under this Agreement may be used

for any activity that promotes the legalization of any drug or other substance

included in schedule I of the schedules of controlled substances established under

section 202 of the Controlled Substances Act except for normal and recognized

executive congressional communications. This limitation shall not apply when

there is significant medical evidence of a therapeutic advantage to the use of such

drug or other substance of that federally sponsored clinical trials are being

conducted to determine therapeutic advantage.

6. Resource Conservation and Recovery. Recipient shall comply and require all subcontractors to comply with all mandatory

standards and policies that relate to resource conservation and recovery pursuant to the

Resource Conservation and Recovery Act (codified at 42 U.S.C. 6901 et. seq.). Section

6002 of that Act (codified at 42 U.S.C. 6962) requires that preference be given in

procurement programs to the purchase of specific products containing recycled materials

identified in guidelines developed by the Environmental Protection Agency. Current

guidelines are set forth in 40 CFR Part 247.

7. Audits. a. Recipient shall comply, and require all subcontractors to comply, with applicable

audit requirements and responsibilities set forth in this Agreement and applicable

state or federal law.

b. If Recipient expends $500,000 or more in Federal funds (from all sources) in its

fiscal year beginning prior to December 26, 2014, Recipient shall have a single

organization-wide audit conducted in accordance with the Single Audit Act. If

Recipient expends $750,000 or more in federal funds (from all sources) in a fiscal

year beginning on or after December 26, 2014, Recipient shall have a single

organization-wide audit conducted in accordance with the provisions of 2 CFR

Subtitle B with guidance at 2 CFR Part 200. Copies of all audits must be submitted

to OHA within 30 days of completion. If Recipient expends less than $500,000 in

Federal funds in a fiscal year beginning prior to December 26, 2014, or less than

$750,000 in a fiscal year beginning on or after that date, Recipient is exempt from

Federal audit requirements for that year. Records must be available as provided in

Exhibit B, “Records Maintenance, Access”.

8. Debarment and Suspension. Recipient shall not permit any person or entity to be a subcontractor if the person or entity

is listed on the non-procurement portion of the General Service Administration’s “List of

Parties Excluded from Federal Procurement or Nonprocurement Programs” in accordance

with Executive Orders No. 12549 and No. 12689, “Debarment and Suspension” (See 2

CFR Part 180). This list contains the names of parties debarred, suspended, or otherwise

excluded by agencies, and contractors declared ineligible under statutory authority other


than Executive Order No. 12549. Subcontractors with awards that exceed the simplified

acquisition threshold shall provide the required certification regarding their exclusion status

and that of their principals prior to award.

9. Drug-Free Workplace. Recipient shall comply and cause all subcontractors to comply with the following

provisions to maintain a drug-free workplace: (i) Recipient certifies that it will provide a

drug-free workplace by publishing a statement notifying its employees that the unlawful

manufacture, distribution, dispensation, possession or use of a controlled substance, except

as may be present in lawfully prescribed or over-the-counter medications, is prohibited in

Recipient’s workplace or while providing services to OHA Clients. Recipient’s notice shall

specify the actions that will be taken by Recipient against its employees for violation of

such prohibitions; (ii) Establish a drug-free awareness program to inform its employees

about: The dangers of drug abuse in the workplace, Recipient’s policy of maintaining a

drug-free workplace, any available drug counseling, rehabilitation, and employee assistance

programs, and the penalties that may be imposed upon employees for drug abuse

violations; (iii) Provide each employee to be engaged in the performance of services under

this Agreement a copy of the statement mentioned in paragraph (i) above; (iv) Notify each

employee in the statement required by paragraph (i) above that, as a condition of

employment to provide services under this Agreement, the employee will: abide by the

terms of the statement, and notify the employer of any criminal drug statute conviction for a

violation occurring in the workplace no later than five (5) days after such conviction; (v)

Notify OHA within ten (10) days after receiving notice under subparagraph (iv) above from

an employee or otherwise receiving actual notice of such conviction; (vi) Impose a sanction

on, or require the satisfactory participation in a drug abuse assistance or rehabilitation

program by any employee who is so convicted as required by 41 U.S.C. 8104; (vii) Make a

good-faith effort to continue a drug-free workplace through implementation of

subparagraphs (i) through (vi) above; (viii) Require any subcontractor to comply with

subparagraphs (i) through (vii) above; (ix) Neither Recipient, or any of Recipient’s

employees, officers, agents or subcontractors may provide any service required under this

Agreement while under the influence of drugs. For purposes of this provision, "under the

influence" means: observed abnormal behavior or impairments in mental or physical

performance leading a reasonable person to believe the Recipient or Recipient’s employee,

officer, agent or subcontractor has used a controlled substance, prescription or non-

prescription medication that impairs the Recipient or Recipient’s employee, officer, agent

or subcontractor’s performance of essential job function or creates a direct threat to OHA

Clients or others. Examples of abnormal behavior include, but are not limited to:

hallucinations, paranoia or violent outbursts. Examples of impairments in physical or

mental performance include, but are not limited to: slurred speech, difficulty walking or

performing job activities; and (x) Violation of any provision of this subsection may result in

termination of the Agreement.

10. Pro-Children Act. Recipient shall comply and require all subcontractors to comply with the Pro-Children Act

of 1994 (codified at 20 U.S.C. 6081 et. seq.).


11. Medicaid Services. Recipient shall comply with all applicable federal and state laws and regulation pertaining

to the provision of Medicaid Services under the Medicaid Act, Title XIX, 42 U.S.C. 1396

et. seq., including without limitation:

a. Keep such records as are necessary to fully disclose the extent of the services

provided to individuals receiving Medicaid assistance and shall furnish such

information to any state or federal agency responsible for administering the

Medicaid program regarding any payments claimed by such person or institution

for providing Medicaid Services as the state or federal agency may from time to

time request. 42 U.S.C. 1396a (a)(27); 42 CFR Part 431.107(b)(1) & (2).

b. Comply with all disclosure requirements of 42 CFR Part 1002.3(a) and 42 CFR

Part 455 Subpart (B).

c. Maintain written notices and procedures respecting advance directives in

compliance with 42 U.S.C. 1396(a)(57) and (w), 42 CFR Part 431.107(b)(4), and

42 CFR Part 489 Subpart I.

d. Certify when submitting any claim for the provision of Medicaid Services that the

information submitted is true, accurate and complete. Recipient shall acknowledge

Recipient’s understanding that payment of the claim will be from federal and state

funds and that any falsification or concealment of a material fact may be prosecuted

under federal and state laws.

e. Entities receiving $5 million or more annually (under this Agreement and any other

Medicaid contract) for furnishing Medicaid health care items or services shall, as a

condition of receiving such payments, adopt written fraud, waste and abuse policies

and procedures and inform employees, contractors and agents about the policies

and procedures in compliance with Section 6032 of the Deficit Reduction Act of

2005, 42 U.S.C. 1396a(a)(68).

12. Agency-based Voter Registration. If applicable, Recipient shall comply with the Agency-based Voter Registration sections of

the National Voter Registration Act of 1993 that require voter registration opportunities be

offered where an individual may apply for or receive an application for public assistance.

13. Disclosure.

a. 42 CFR Part 455.104 requires the State Medicaid agency to obtain the following

information from any provider of Medicaid or CHIP services, including fiscal

agents of providers and managed care entities: (1) the name and address (including

the primary business address, every business location and P.O. Box address) of any

person (individual or corporation) with an ownership or control interest in the

provider, fiscal agent or managed care entity; (2) in the case of an individual, the

date of birth and Social Security Number, or, in the case of a corporation, the tax

identification number of the entity, with an ownership interest in the provider, fiscal

agent or managed care entity or of any subcontractor in which the provider, fiscal

agent or managed care entity has a 5% or more interest; (3) whether the person

(individual or corporation) with an ownership or control interest in the provider,

fiscal agent or managed care entity is related to another person with ownership or

control interest in the provider, fiscal agent or managed care entity as a spouse,

parent, child or sibling, or whether the person (individual or corporation) with an

ownership or control interest in any subcontractor in which the provider, fiscal

agent or managed care entity has a 5% or more interest is related to another person


with ownership or control interest in the provider, fiscal agent or managed care

entity as a spouse, parent, child or sibling; (4) the name of any other provider, fiscal

agent or managed care entity in which an owner of the provider, fiscal agent or

managed care entity has an ownership or control interest; and, (5) the name,

address, date of birth and Social Security Number of any managing employee of the

provider, fiscal agent or managed care entity.

b. 42 CFR Part 455.434 requires as a condition of enrollment as a Medicaid or CHIP

provider, to consent to criminal background checks, including fingerprinting when

required to do so under state law, or by the category of the provider based on risk of

fraud, waste and abuse under federal law.

c. As such, a provider must disclose any person with a 5% or greater direct or indirect

ownership interest in the provider whom has been convicted of a criminal offense

related to that person's involvement with the Medicare, Medicaid, or Title XXI

program in the last 10 years.

d. Recipient shall make the disclosures required by this Section to OHA. OHA

reserves the right to take such action required by law, or where OHA has discretion,

it deems appropriate, based on the information received (or the failure to receive

information) from the provider, fiscal agent or managed care entity.

14. Federal Intellectual Property Rights Notice.

The federal funding agency, as the awarding agency of the funds used, at least in part, for

the activities performed under this Agreement, may have certain rights as set forth in the

federal requirements pertinent to these funds. For purposes of this subsection, the terms

“grant” and “award” refer to funding issued by the federal funding agency to the State of

Oregon. The Recipient agrees that it has been provided the following notice:

a. The federal funding agency reserves a royalty-free, nonexclusive and irrevocable right

to reproduce, publish, or otherwise use the work, and to authorize others to do so, for

Federal Government purposes with respect to:

(1) The copyright in any work developed under a grant, subgrant or contract under a

grant or subgrant; and

(2) Any rights of copyright to which a grantee, subgrantee or a contractor purchases

ownership with grant support.

b. The parties are subject to applicable federal regulations governing patents and

inventions, including government-wide regulations issued by the Department of

Commerce at 37 CFR Part 401, “Rights to Inventions Made by Nonprofit Organizations

and Small Business Firms Under Government Grants, Contracts and Cooperative

Agreements.”

c. The parties are subject to applicable requirements and regulations of the federal funding

agency regarding rights in data first produced under a grant, subgrant or contract under

a grant or subgrant.

EXHIBIT E

Required Subcontractor Provisions

[Optional]


EXHIBIT F

Information Required by 2 CFR Subtitle B with guidance at 2 CFR Part 200

1. Federal Award Identification:

2. Recipient Name (which must match the name associated with 3. Below):

3. Recipient’s Unique Entity Identifier (i.e. DUNS number):

4. Federal Award Identification Number (FAIN):

5. Federal Award Date:

6. Period of Performance Start and End Date: From: To:

7. Total Amount of Federal Funds Obligated by this Agreement:

a. Total Amount of Federal Award:

(1) Federal Award Project Description:

(2) Name of Federal Awarding Agency:

(3) Contact Information for Awarding Official:

(4) Indirect Cost Rate:

(a) CFDA Number and Name: Amount:

(b) CFDA Number and Name: Amount:

(c) CFDA Number and Name: Amount:

8. Total Amount of Federal Funds Obligated to Recipient:

9. Is Award Research and Development? Yes No