Backup Documents 06/14-15/2011 Item #16D7
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIM 6 D 7
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO ~
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. Original documents should be hand delivered to the Board Office. The completed routing slip and original
documents are to be forwarded to the Board Office only after the Board has taken action on the item.)
ROUTING SLIP
Complete routing lines # I through #4 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the
excention of the Chairman's signature. draw a line througt routing lines #1 through #4, comnlete the checklist, and forward to Sue Filson (line #5\.
Route to Addressee(s) Office Initials Date
(List in routing order)
I.Jennifer B. White County Attorney '?<?W (P\\CS\~
2. Ian Mitchell, Executive Manager to Board of County Commissioners Av- ~/1~/tI
the BCC
3. Minutes and Records Clerk of Court's Office
4.
5.
6.
\
PRIMARY CONTACT INFORMATION
(The primary contact is the holder of the original document pending BCC approval. Normally the primary contact is the person who created/prepared the executive
summary. Primary contact information is needed in the event one of the addressees above, including Ian Mitchell, need to contact stafffor additional or missing
item.)
information. All original documents needing the BCC Chairman's siQ11ature are to be delivered to the BCC office onlv after the BCC has acted to aoorove the
Name of Primary Staff Rosa Munoz, Grants Coordinator Phone Number 252-5713
Contact
Agenda Date Item was June 14,2011 Agenda Item Number 1607/2113
Aooroved bv the BCC
Type of Document HRSA Agreement Number of Original I
Attached Documents Attached
1.
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark "N/A" in the Not Applicable column, whichever is
a ro riate.
Original document has been signed/initialed for legal sufficiency. (All documents to be
signed by the Chairman, with the exception of most letters, must be reviewed and signed
by the Office of the County Attorney. This includes signature pages from ordinances,
resolutions, etc. signed by the County Attorney's Office and signature pages from
contracts, agreements, etc. that have been fully executed by all parties except the BCC
Chairman and Clerk to the Board and ossibl State Officials.)
All handwritten strike-through and revisions have been initialed by the County Attorney's
Office and all other arties exce t the BCC Chairman and the Clerk to the Board
The Chairman's signature line date has been entered as the date ofBCC approval ofthe
document or the final ne otiated contract date whichever is a licable.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
si nature and initials are re uired.
In most cases (some contracts are an exception), the original document and this routing slip
should be provided Ian Mitchell in the BCC office within 24 hours ofBCC approval. Some
documents are time sensitive and require forwarding to Tallahassee within a certain time
frame or the BCC's actions are nullified. Be aware of our deadlines!
The document was approved by the BCC on June 14,2011 (enter date) and all
changes made during the meeting have been incorporated in the attached document,
The Count Attorne 's Office has reviewed the chan es, if a licable,
Yes
(Initial)
RM
N/A (Not
A licable)
2.
3.
4.
5.
6.
NA
RM
RM
NA
RM
I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05, Revised 9.18.09
16 D 7
MEMORANDUM
Date:
June 17,2011
To:
Rosa Munoz, Grants Coordinator
Housing, Human & Veteran Services
From:
Ann J ennej 000, Deputy Clerk
Minutes & Records Department
Re:
Agreement with Physician Led Access Network
(PLAN) of Collier County providing funds for a
shared information network for PLAN participants
Attached is an original copy of the agreement referenced above (Item #16D7),
approved by the Board of County Commissioners on Tuesday, June 14, 2011.
The Minutes and Record's Department has held the second original
agreement for the Board's Official Record.
If you have any questions, please feel free to contact me at 252-8406.
Thank you.
Attachment
16D 7
AGREEMENT
FOR
PHYSICIAN LED ACCESS NETWORK OF COLLIER COUNTY (PLAN),
CFDA: 93.888
GRANT #DIARH20098 HRSA
THIS AGREEMENT, made and entered into on this \4- day of 20lL, by
and between Physician Led Access Network (PLAN) of Collier unty, authorized to do
business in the State of Florida whose business address is 1012 Goodlette-Frank Rd., Suite
#201, Naples, Florida 34102, hereinafter called the "Subrecipient" and Collier County, a
political subdivision of the State of Florida, Collier County, Naples, hereinafter call the
"County" :
WITNESSETH:
1. COMMENCEMENT: The Agreement shall be for a twenty-four (24) month period,
commencing on the date assigned by the u.s. Department of Health and Human
Services, Health Resources and Services Administration (HRSA); September 1, 2010,
and terminating on August 31, 2012.
2. STATEMENT OF WORK: The Subrecipient shall provide services in accordance with
the Scope of Services, included in Attachment A. Additional related services may be
provided by the Subrecipient subject to the issuance of Change Orders as approved in
advance by the County.
3. COMPENSATION: The County shall pay for contracted services performed on behalf
of PLAN for the performance of this Agreement a total amount of Four Hundred
Eighty-Eight Thousand dollars, ($488,000) based on allowable expenses incurred.
Allowable costs associated with the project are included in Attachment A.
Payment will be made to project vendors upon receipt of a proper invoice and in
compliance with Section 218.70 Florida Statutes, otherwise known as the "Florida
Prompt Payment Act" and a signed affidavit from the PLAN Executive Director,
attesting that the work has been completed. Collier County reserves the right to
withhold and/ or reduce an appropriate amount of any payments for work not
performed or for unsatisfactory performance of Contractual requirements.
The County and us Department of Health and Human Services, Health Resources
and Services Administration have agreed that these funds will only be used to fund
projects that demonstrate expertise in the area of Rural Health Outreach Special
Initiative.
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4. SALES TAX: Subrecipient shall pay all sales, consumer, use and other similar taxes
associated with this Agreement.
5. NOTICES: All notices from the County to the Subrecipient shall be deemed duly
served if mailed or faxed to the Subrecipient at the following address:
Physician Led Access Network (PLAN)
of Collier County, Inc.
1012 Goodlette-Frank Rd., Suite #201
Naples, Florida 34102
Margaret Eadington, Chair of PLAN Board
Phone: (239) 434-0008
Fax: 239-417-8900
All notices from the Subrecipient to the County shall be deemed duly served if mailed
or faxed to the County to:
Collier County Government Center
Housing, Human and Veteran Services Department
3339 E. Tamiami Trail, Suite 211
Naples, Florida 34112
Attn: Marcy Krumbine, Director
Phone: 239-252-2273
Fax: 239-252-2638
The Subrecipient and the County may change the above mailing address at any time
upon giving the other party written notification. All notices under this Agreement
must be in writing.
6. NO PARTNERSHIP: Nothing herein contained shall create or be construed as
creating a partnership between the County and the Subrecipient or to constitute the
Subrecipient as an agent of the County.
7. SPECIAL CONDITIONS: The Subrecipient agrees to comply with the requirements
set forth in Attachment B.
8. SUBCONTRACTS: Any work or services subcontracts by the Subrecipient shall be
specifically by written contract or agreements, and such subcontracts shall be subject
to each provision of this Agreement and applicable County, State, and Federal
guidelines and regulations. Prior to execution by the Subrecipient of any subcontract
hereunder, such subcontracts must be submitted by the Subrecipient to Housing,
Human and Veteran Services (HHVS) for its review and approval. None of the work
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or services covered by the Agreement, including but not limited to consultant work or
services, shall be subcontracted by the Subrecipient or reimbursed by the County
without prior written approval of the Housing, Human and Veteran Services Director
or his designee.
9. AMENDMENTS: The County may, at its discretion, amend this Agreement to
conform to changes required by HRSA guidelines, directives, and objectives. Such
amendments shall be incorporated by written amendment as a part of this Agreement
and shall be subject to approval of Collier County. Except as otherwise provided
herein, no amendment to this Agreement shall be binding on either party unless in
writing, approved by the County and signed by each Party's designee.
10. PERMITS: LICENSE TAXES: In compliance with Section 218.80, F.s., all permits
necessary for the prosecution of the Work shall be obtained by the Subrecipient.
Payment for all such permits issued by the County shall be processed internally by the
County. All non-County permits necessary for the prosecution of the Work shall be
procured and paid for by the Subrecipient. The Subrecipient shall also be solely
responsible for payment of any and all taxes levied on the Subrecipient. In addition,
the Subrecipient shall comply with all rules, regulations and laws of Collier County,
the State of Florida, or the U. S. Government now in force or hereafter adopted. The
Subrecipient agrees to comply with all laws governing the responsibility of an
employer with respect to persons employed by the Subrecipient.
11. NO IMPROPER USE: The Subrecipient will not use, nor suffer or permit any person
to use in any manner whatsoever, County facilities for any improper, immoral or
offensive purpose, or for any purpose in violation of any federal, state, county or
municipal ordinance, rule, order or regulation, or of any governmental rule or
regulation now in effect or hereafter enacted or adopted. In the event of such violation
by the Subrecipient or if the County or its authorized representative shall deem any
conduct on the part of the Subrecipient to be objectionable or improper, the County
shall have the right to suspend the contract of the Subrecipient. Should the
Subrecipient fail to correct any such violation, conduct, or practice to the satisfaction of
the County within twenty-four (24) hours after receiving notice of such violation,
conduct, or practice, such suspension to continue until the violation is cured. The
Subrecipient further agrees not to commence operation during the suspension period
until the violation has been corrected to the satisfaction of the County.
12. PROHIBITION OF GIFTS TO COUNTY EMPLOYEES: No organization or
individual shall offer or give, either directly or indirectly, any favor, gift, loan, fee,
service or other item of value to any County employee, as set forth in Chapter 112,
Part III, Florida Statutes, Collier County Ethics Ordinance No. 2004-53, and County
Administrative Procedure 5311. Violation of this provision may result in one or more
of the following consequences: a. Prohibition by the individual, firm, and/ or any
employee of the firm from contact with County staff for a specified period of time; b.
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Prohibition by the individual and! or firm from doing business with the County for a
specified period of time, including but not limited to: submitting bids, RFP, and! or
quotes; and, c. immediate termination of any contract held by the individual and! or
firm for cause.
13. TERMINATION: Should the Subrecipient be found to have failed to perform his
services in a manner satisfactory to the County as per this Agreement, the County may
terminate this Agreement immediately for cause; further, the County may terminate
this Agreement for convenience with a seven (7) day written notice. The County shall
be sole judge of non-performance.
14. NO DISCRIMINATION: The Subrecipient agrees that there shall be no
discrimination as to race, sex, color, creed or national origin.
a. Executive Order 13166, August 11, 2000 requires recipients receiving Federal
financial assistance to take steps to ensure that people with limited English
proficiency can meaningfully access health and social services. Subrecipient's
organization must comply with this requirement as set forth in Attachment A,
page 4 item 9.
15. INSURANCE: The Subrecipient shall provide insurance as follows:
A. Commercial General Liability: Coverage shall have minimum limits of $1,000,000
Per Occurrence, Combined Single Limit for Bodily Injury Liability and Property
Damage Liability. This shall include Premises and Operations; Independent
Contractors; Products and Completed Operations and Contractual Liability.
B. Business Auto Liability: Coverage shall have minimum limits of $500,000 Per
Occurrence, Combined Single Limit for Bodily Injury Liability and Property
Damage Liability. This shall include: Owned Vehicles, Hired and Non-Owned
Vehicles and Employee Non-Ownership.
C. Workers' Compensation: Insurance covering all employees meeting Statutory
Limits in compliance with the applicable state and federal laws.
The coverage must include Employers' Liability with a minimum limit of
$1,000,000 for each accident.
Special Requirements: Collier County shall be listed as the Certificate Holder and
included as an Additional Insured on the Comprehensive General Liability
Policy.
Current, valid insurance policies meeting the requirement herein identified shall
be maintained by Subrecipient during the duration of this Agreement. Renewal
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certificates shall be sent to the County 30 days prior to any expiration date. There
shall be a 30 day notification to the County in the event of cancellation or
modification of any stipulated insurance coverage.
Subrecipient shall insure that all subcontractors comply with the same insurance
requirements that he is required to meet. The same Subrecipient shall provide
County with certificates of insurance meeting the required insurance provisions.
16. INDEMNIFICATION: To the maximum extent permitted by Florida law, the
Subrecipient shall indemnify and hold harmless Collier County, its officers and
employees from any and all liabilities, damages, losses and costs, including, but not
limited to, reasonable attorneys' fees and paralegals' fees, to the extent caused by the
negligence, recklessness, or intentionally wrongful conduct of Subrecipient or
Consultant or anyone employed or utilized by the Subrecipient or Consultant in the
performance of this Agreement. This indemnification obligation shall not be
construed to negate, abridge or reduce any other rights or remedies which otherwise
may be available to an indemnified party or person described in this paragraph. This
section does not pertain to any incident arising from the sole negligence of Collier
County. The foregoing indemnification shall not constitute a waiver of sovereign
immunity beyond the limits set forth in Section 768.28, Florida Statutes.
17. CONTRACT ADMINISTRATION: This Agreement shall be administered on behalf
of the County by the HHVS Department.
18. REPORTS, AUDITS, AND EVALUATIONS: Reimbursement will be contingent on the
timely receipt of complete and accurate reports required by this Agreement, and on the
resolution of monitoring or audit findings identified pursuant to this Agreement.
The Subrecipient agrees that HHVS will carry out periodic monitoring and evaluation
activities as determined necessary. The continuation of this Agreement is dependent upon
satisfactory evaluations. The Subrecipient shall, upon the request of HHVS, submit
information and status reports required by HHVS or HRSA to enable HHVS to evaluate said
progress and to allow for completion of reports required. The Subrecipient shall allow HHVS
or HRSA to monitor the Subrecipient on site. Such site visits may be scheduled or
unscheduled as determined by HHVS or HRSA.
19. CONFLICT OF INTEREST: Subrecipient represents that it presently has no interest
and shall acquire no interest, either direct or indirect, which would conflict in any
manner with the performance of services required hereunder. Subrecipient further
represents that no persons having any such interest shall be employed to perform
those services.
20. COMPONENT PARTS OF THIS AGREEMENT: This Agreement consists of the
following attachments, all of which are fully part of the Agreement: Attachment A _
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Scope of Services; Attachment B - Budget Summary; Attachment C - Special
Conditions.
21. SUBJECT TO APPROPRIATION: It is further understood and agreed by and
between the parties herein that this Agreement is subject to appropriation by the
Board of County Commissioners.
22. GRANT CLOSEOUT PROCEDURES: SUB RECIPIENT' s obligation to the COUNTY
shall not end until all closeout requirements are completed. Activities during this
closeout period shall include, but not be limited to: making final payments, disposing
of program assets (including the return of all unused materials, equipment, unspent
cash advances, program income balances, and receivable accounts to the COUNTY),
and determining the custodianship of records.
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IN WITNESS WHEREOF, the Subrecipient and the County, have each, respectively, by an
author~d person or agent, hereunder set their hands and seals on this 1'1- day of
~, ,20lL.
BOARD OF COUNTY COMMISSIONERS OF
COLLIER COUNTY, FLORIDA
By: ~W. ~
FRED W. COYLE, CHAI
FiistWitness
Physician Led Access Network (PLAN)
of Collier County
By: -!l1, [A~'~ 1 ( 0^-
Subr cipient Signature I,J
11 Wlmess
t- J- ('~~
~ b {ec-e 1/<-
Type/print witness name
Margaret Eadington. Chair.
Type/print Subrecipient name and title
Approved as to form and legal sufficiency:
~~~
Jennifer . WhIte
Assistant County Attorney
frem # \(Q1rt
Agenda I /l.J \LJ l
OGle \kC!.I.J
~:~~d &-t~ l
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ATTACHMENT "A"
SCOPE OF SERVICES
1607
PHYSICIAN LED ACCESS NETWORK OF COLLIER COUNTY (PLAN)
A. PROTECT SCOPE:
On October 12, 2010, agenda item 16D4; the Board of Commissioners approved the Rural
Health Outreach Special Congressional Initiative from the United States Department of Health
and Human Services (HRSA) Grant in the amount of $594,000.
This grant funding for Physician Led Access Network of Collier County (PLAN) will be used
to pay salary and benefits for the Executive Director, Systems Coordinator, Program Manager,
Primary Care Coordinator, and for the Administrative Program Associate. Funds will also be
used for Travel, Supplies; General, Recruitment Marketing, Recruitment Marketing Brochures,
Care Material, minor office furniture, Laboratory & Pharmacy Vouchers,
Consultants/Contracts, Laboratory Subsidy, Pharmacy Services, Marketing Development,
Public Relations, Video Modification, Website development/Enhancement, Financial Services
(includes annual audit/ acct svc), Rent, Utilities, and Insurance (portion of liability)
B. BUDGET:
Collier County Housing, Human and Veteran Services is providing Four Hundred Eighty-
Eight Thousand Dollars ($488,000.00) in HRSA funding for the project scope described above.
Line Item Description
Personnel - PLAN Salary and benefits
Project Manager/Executive Director
Systems Coordinator
Program Manager
Primary Care Coordinator
Administrative Program Associate
Program Operating
Travel, Supplies; General, Recruitment Marketing, Recruitment
Marketing Brochures, Care Material, minor office furniture,
Laboratory & Pharmacy Vouchers, Consultants/Contracts,
Laboratory Subsidy, Pharmacy Services, Marketing Development,
Public Relations, Video Modification, Website
development/Enhancement, Financial Services (includes annual
audit/ acct svc), Rent, Utilities, and Insurance (portion of liability)
TOTAL
HRSA Funds
$204,375.00
$283,625.00
$488,000,00
Any modifications to this contract shall be in compliance with the County Purchasing Policy
and Administrative Procedures in effect at the time such modifications are authorized.
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C. PROJECT WORK PLAN:
The following Project Work Plan is in effect for program monitoring requirements only and as
such, is not intended to be used as a payment schedule.
Date Start
9/2010
Date End
08/2012
Work Plan
Demonstrate that 300-500 new patients annually have
been enrolled as documented b monthl re orts
Demonstrate that a minimum of 35 new physicians
were added for rimar care
9/2010
08/2012
D. PAYMENT SCHEDULE:
The following table details the project deliverables and payment schedule.
Deliverable
Payment Schedule
Salary
Operations
U on invoicin of allowable ex enses
U on invoicin of allowable ex enses
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ATTACHMENTB
Special Conditions
Compliance with Local and Federal Rules, Regulations and Laws
During the performance of this Agreement, the Subrecipient agrees to comply with any
applicable laws, regulations and orders listed below by reference and incorporated and made
a part hereof:
1. 24 CFR Part 1 - The regulations promulgated pursuant to Title VI of the 1984 Civil
Rights Act.
2. Age Discrimination Acts of 1973.
3. OMB Circular A-133 concerning audits.
4. Executive Order 11914 - Prohibits discrimination with respect to the handicapped in
federally assisted projects.
5. Chapter 112, Florida Statutes - which deals with conflict of interests.
6. 45 CFR Part 74.25 Revision of budget and program plans.
7. OMB Circular A-122 - concerning cost principles.
8. 24 CFR Part 84 - Uniform Administrative Requirements for Grants and Agreements
with Institutions of Higher Education, Hospitals and Non-Profit Organizations.
9. Notice of Grant Award Authorization (Legislation/Regulation) Public Health Service
Act, Title III, Section 330 A Section 711(b) of the Social Security Act, 42 U.s. c. 912(b)
Public Health Service Act, Section 330A (e) (42 U.s. c. 254(c), and the Consolidated
Appropriations Act of 2008, Public Law 110-161.
Written Approvals
The following items will require written approval by the County:
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1.
All subcontracts and agreements proposed to be entered into by the Subrecipient
pursuant to this Agreement;
All capital equipment expenditures of $1,000 or more;
All out-of-town travel (travel shall be reimbursed in accordance with Chapter 112,
Fla. Stat.;
All change orders;
All requests to utilize uncommitted funds after the expiration of this Agreement
for programs described in Attachment" A"; and
All rates of pay and pay increases paid out of HRSA funds, whether for merit or
cost of living.
2.
3.
4.
5.
6.
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Purchasing
All purchasing for services and goods, including capital equipment, shall be made by
purchase order or by a written contract and in conformity with the procedures prescribed by
the Federal Management Circulars A-llO, A-122, 24 CFR Part 84, and 24 CFR Part 85.
Audits and Inspections
1. Non-profit organizations that expend $500,000 or more annually in federal awards
shall have a single or program-specific audit conducted for that year in accordance
with OMB A-133, Non-profit organizations expending federal awards of $500,000
or more under only one federal program may elect to have a program-specific
audit performed in accordance with OMB A-133.
2. Non-profit organizations that expend less than $500,000 annually in federal awards
shall be exempt from an audit conducted in accordance with OMB A-133, although
their records must be available for review (e.g., inspections, evaluations). These
agencies are required by HHVS to submit "Reduced Scope" audits (e.g., financial
audit, performance audits). They may choose, instead of a Reduced Scope Audit,
to have a program audit conducted for each federal award in accordance with
federal laws and regulations governing the program in which they participate.
3. When the requirements of OMB A-133 apply, or when the Subrecipient elects to
comply with OMB A-133, an audit shall be conducted for each fiscal year for which
federal awards attributable to this contract have been received by the Subrecipient.
A copy of the audit report must be received by HHVS no later than six months
following the end of the Subrecipient's fiscal year.
4. If an audit is required but the requirements of OMB A-133 do not apply or are not
elected, the Subrecipient may choose to have an audit performed either on the basis
of the Subrecipient's fiscal year or on the basis of the period during which HHVS-
federal assistance has been received. In either case, each audit shall cover a time
period of not more than twelve months and an audit shall be submitted covering
each assisted period until all the assistance received from this contract has been
reported. Each audit shall adhere to all other audit standards of OMB A-133, as
these may be limited to cover only those services undertaken pursuant to the terms
of this contract. A copy of the audit report must be received by HHVS no later
than six months following each audit period.
5. The Subrecipient shall maintain all contract records in accordance with generally
accepted accounting principles, procedures, and practices which shall sufficiently
and properly reflect all revenues and expenditures of funds provided directly or
indirectly by the County pursuant to the terms of this Agreement.
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6. The Subrecipient shall include in all HHVS approved subcontracts each of the
record-keeping and audit requirements detailed in this contract.
Grant Terms and Conditions
1. This Agreement is subject to the HHVS Grants Policy Statement (HHVS GPS),
currently available at http://www.hrsa.gov / grants/hhsgrantspolicy.pdf
2. Recipients and sub-recipients of Federal funds are subject to the strictures of the
Medicare and Medicaid anti-kickback statute (42 U.s.e. 1320a -7b(b) and should be
cognizant of the risk of criminal and administrative liability under this statute,
specifically under 42 U.s.e. 1320 7b(b) Illegal remunerations which states, in part, that
whoever knowingly and willfully:
(A) Solicits or receives (or offers or pays) any remuneration (including kickback, bribe,
or rebate) directly or indirectly, overtly or covertly, in cash or in kind, in return for
referring (or to induce such person to refer) an individual to a person for the
furnishing or arranging for the furnishing of any item or service, OR
(B) In return for purchasing, leasing, ordering, or recommending purchasing, leasing,
or ordering, or to purchase, lease, or order, any goods, facility, services, or item for
which payment may be made in whole or in part under subchapter XIII of this chapter
or a State health care program, shall be guilty of a felony and upon conviction thereof,
shall be fined not more than $25,000 or imprisoned for not more than five years, or
both.
3. EO 13166, August 11, 2000, requires recipients receiving Federal financial assistance to
take steps to ensure that people with limited English proficiency can meaningfully
access health and social services. A program of language assistance should provide for
effective communication between the service provider and the person with limited
English proficiency to facilitate participation in, and meaningful access to, services.
The obligations of recipients are explained on the OCR website at
http://www.hhs.gov / ocr/lep/revisedlep.html.
4. This award is subject to the requirements of Section 106 (g) of the Trafficking Victims
Protection Act of 2000,as amended (22 U.s.e. 7104). For the full text of the award term,
go to http://www.hrsa.gov/grants/trafficking.htm
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ATTACHMENTC
PHYSICIAN LED ACCESS NETWORK OF COLLIER COUNTY (PLAN),
REQUEST FOR PAYMENT
SECTION I: REQUEST FOR PAYMENT
Subrecipient Name: Phvsician Led Access Network of Collier Countv (PLAN)
Subrecipient Address: 1012 Goodlette Frank Rd.. Suite #20 1 Naples. FL 34102
Project Name: HRSA Earmark III )
Payment Request #
Dollar Amount Requested: $
SECTION II: STATUS OF FUNDS
1. Grant Amount Awarded
$
488,000.00
2. Sum of Past Claims Paid on this Account
$
3. Total Grant Amount Awarded Less Sum
Of Past Claims Paid on this Account
4. Amount of Previous Unpaid Requests
$
$
5. Amount of Today's Request
$
6. Current Grant Balance (Initial Grant Amount Awarded
Less Sum of all requests)
$
I certify that this request for payment has been drawn in accordance with the terms and
conditions of the Agreement between the COUNTY and us, as the Subrecipient. I also certify that the
amount of the Request for Payment is not in excess of current needs.
Signature
Date
Title
Authorizing Grant Coordinator
Supervisor
Dept Director
(approval authority under $14,999)
(approval required $15,000 and above)
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ATTACHMENT C
HRSA MONTHLY PROGRESS REPORT
Complete form for past month and submit to Housing, Human Veteran Service's staffby the
1 (jh of the following month.
Status Report for Month of
Submittal Date:
Project Name HRSA Earmark III
Subrecipient:
Physician Led Access Network of Collier County (PLAN)
Contact Person
Deb Cecere. Executive Director
Telephone:
239) 776-3016
Fax: 239-417-8900
E-mail :
deb@plancc.org
1. Activity Status/Milestones (describe any action taken, relating to this project, during
the past month):
2. What events/actions are scheduled for the next two months?
3. Describe any affirmative marketing you have implemented regarding this project.
Please list and attach any recent media coverage of your organization relating to this project.
4. List any additional data relevant to the outcome measures listed on the application
for this project.
5. Identify any potential issues that may cause delay.
6, New contracts executed this month (if applicable):
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Name of Physician or Physician, Amount of Subrecipient Race Ethnicity
Address & Phone Number Contract Federal ID (see definitions on (see definitions on
If Applicable Number following page) following page)
If Applicable
For projects that serve a particular clientele, please complete the following information by
entering the appropriate number in the blank spaces and in the chart below. Complete the below chart
for NEW primary care clients served this month. DO NOT DUPLICATE clients served in previous
months. You may provide data by either households or persons served. However, if one person
received TWO services this counts as TWO SERVICE UNITS:
TOTAL BENEFICIARIES
This project benefits households or persons. Please circle one category (either
"households" or "persons"). Enter the number of beneficiaries in the blank space and in Box 1. "
INCOME
Of the households or persons assisted, are extremely low-income income (0-30%) of the
current Median Family Income (MFI). Enter this number in Box "2. "
Of the households or persons assisted, are very low-income (31-50%) of the current
Median Family Income (MFI). Enter this number in Box "3. "
Of these households or persons assisted, are low-income (51-80%) of the current Median
Family Income (MFI). Enter this number in Box "4. "
NOTE: The total of Boxes 2, 3 and 4 should equal the number in Box 1.
FEMALE HEAD OF HOUSEHOLD
This project assisted
number in box "5" below.
Female Head of Households REGARDLESS of income. Enter this
BOX 1 BOX 2 BOX 3 BOX 4 BOX 5
Total Number of Extremely Very Low Income Female Head of
Households or Low Income Low Income (51-80%) Household
Persons Assisted (0-30%) (31-50%)
2010 HRSA
PLAN
Earmark 111
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16D 7
Subrecipient's must indicate total beneficiaries for Race AND Ethnicity
Definitions of Race:
White: A person having origins in any ofthe original peoples of Europe, the Middle East, or North
Africa.
Black or African-American: A person having origins in any of the black racial groups of Africa.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or
the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native: A person having origins in any of the original peoples of North
and South America (including Central America), and who maintains tribal affiliation or community
attachment.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original people of
Hawaii, Guam, Samoa, or other Pacific Islands.
Definitions of Ethnicity:
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture or origin, regardless of race.
Tabulation Table of Race and Ethnicity Beneficiaries
# Hispanic
Race # Total
White
Black or African American
Asian
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
American Indian! Alaska Native and White
Asian and White
Black! African American and White
American Indian! Alaskan Native and Black! African American
Other Multi-Racial
TOT AL:
2010 HRSA
PLAN
Earmark III
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