R-2019-0321 - 8/8/2019 RESOLUTION NO. R-2019-0321
WHEREAS, Chapter 791 of the Texas Government Code, V.T.C.A., authorizes local
governments and agencies of the state to enter into agreements with one another to perform
governmental functions and services, and
WHEREAS, the City of Round Rock wishes to enter into an Interlocal Contract with the
Health and Human Services Commission for funding for the Opioid Emergency Response Pilot
Project,Now Therefore
BE IT RESOLVED BY THE COUNCIL OF THE CITY OF ROUND ROCK, TEXAS,
That the Mayor is hereby authorized and directed to execute on behalf of the City an Interlocal
Contract with the Health and Human Services Commission, a copy of same being attached hereto as
Exhibit"A" and incorporated herein for all purposes.
The City Council hereby finds and declares that written notice of the date, hour, place and
subject of the meeting at which this Resolution was adopted was posted and that such meeting was
open to the public as required by law at all times during which this Resolution and the subject matter
hereof were discussed, considered and formally acted upon, all as required by the Open Meetings Act,
Chapter 551, Texas Government Code, as amended.
RESOLVED this 8th day of August, 2019.
CRAIG;oundORGA ayor
City of R , Texas
ATTEST:
9V4-
SARA
L. WHITE, City Clerk
0112.1902;00428701
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EXHIBIT
„A„
SIGNATURE DOCUMENT FOR
HEALTH AND HUMAN SERVICES COMMISSION
CONTRACT No.HHS000508300001
UNDER THE TEXAS TARGETED OPIOID RESPONSE(TTOR)GRANT PROGRAM
THE HEALTH AND HUMAN SERVICES COMMISSION("System Agency")and CITY OF ROUND ROCK
("Local Government", "Grantee"), each a "Party" and collectively the "Parties," enter into the
following contract to provide funding for the Opioid Emergency Response Pilot Project (the
"Contract")pursuant to the provisions of the"Interlocal Cooperation Act,"Chapter 791 of the Texas
Government Code.
I. PARTIES
System AQencv Local Government
Health and Human Services Commission City of Round Rock
P.O. Box 149347 221 E. Main St.
Austin,TX 78714-9347 Round Rock,TX 78664
Jennifer Molenaar Angelo Luna
512-206-5153 512-218-6625
Jennifer.Molenaar@hhsc.state.tx.us Aluna@roundrocktexas.gov
II. STATEMENT OF SERVICES TO BE PROVIDED
The Parties agree to cooperate to provide necessary and authorized services and resources in
accordance with the terms of this Contract. Specific services provided are described in
Attachment A--Statement of Work.
III. CONTRACT PERIOD AND RENEWAL
The Contract is effective on May 1, 2019 and terminates on September 30, 2019,unless renewed,
extended, or terminated pursuant to the terms and conditions of the Contract. The Parties may
extend this Contract subject to mutually agreeable terms and conditions.
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IV. AMENDMENT
The Parties to this Contract may modify this contract only through the execution of a written
amendment signed by both parties.
V. CONTRACT AMOUNT AND PAYMENT FOR SERVICES
The total amount of this Contract, including all Work Orders issued under it, shall not exceed
FIVE HUNDRED THOUSAND DOLLARS($500,000.00), as provided for in Attachment B -
-Budget.
VI. LEGAL NOTICES
Legal Notices under this Contract shall be deemed delivered when deposited either in the United
States mail,postage paid, certified,return receipt requested; or with a common carrier, overnight,
signature required, to the appropriate address below:
System Agency
Health and Human Services Commission
1100 W. 49th Street, MC 1911
Austin,TX 78756
Attention: Karen Ray,Chief Counsel
Office of Chief Counsel
Local Government
City of Round Rock
221 E. Main Street
Round Rock, Texas 78664
Attention: Angelo Luna
Notice given in any other manner shall be deemed effective only if and when received by the Party
to be notified. Either Party may change its address for receiving legal notice by notifying the other
Party in writing.
VII. CERTIFICATIONS
The undersigned contracting Parties certify that:
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(1) the services specified above are necessary and essential for activities that are properly
within the statutory functions and programs of the affected agencies of state
government;
(2) Each Party executing this Contract on its behalf has full power and authority to enter
into this Contract;
(3) the proposed arrangements serve the interest of efficient and economical
administration of state government; and
(4) the services contracted for are not required by Section 21, Article XVI of the
Constitution of Texas to be supplied under a contract awarded to the lowest
responsible bidder.
The System Agency further certifies that it has statutory authority to contract for the services
described in this contract under Texas Health and Safety Code Chapters 12 and 1001 and Texas
Government Code Chapter 531, Subchapter D,to the extent applicable.
The Local Government further certifies that it has statutory authority to contract for the services
described in this contract under Texas Government Code Chapter 791,The Interlocal
Cooperation Act.
SIGNATURE PAGE FOLLOWS
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SIGNATURE PAGE FOR SYSTEM AGENCY CONTRACT NO.HHS000508300001
HEALTH AND HUMAN SERVICES COMMISSION CITY OF ROUND ROCK
Signature Signature
Printed Name Printed Name
Title Title
Date Date
THE FOLLOWING ATTACHMENTS TO ENTERPRISE AGENCY CONTRACT NO.
HHS000508300001 ARE HEREBY INCORPORATED BY REFERENCE:
ATTACHMENT A-STATEMENT OF WORK
ATTACHMENT A-1-STATEMENT OF WORK SUPPLEMENTAL
ATTACHMENT B—BUDGET
ATTACHMENT C—INTERVENTIONAL PILOT PROGRAM MODEL&
IMPLEMENTATION PLAN
ATTACHMENT D-UNIFORM TERMS AND CONDITIONS
ATTACHMENT E-SPECIAL CONDITIONS
ATTACHMENT F-FEDERAL ASSURANCES AND CERTIFICATIONS
ATTACHMENT G-DATA USAGE AGREEMENT
ATTACHMENT H-GENERAL AFFIRMATIONS
ATTACHMENT I-NON-EXCLUSIVE LIST OF APPLICABLE LAWS
ATTACHMENT J-FEDERAL FUNDING ACCOUNTABILITY AND
TRANSPARENCY ACT(FFATA)
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ATTACHMENT A
STATEMENT OF WORK
I. PURPOSE
The purpose of the Opioid Emergency Response Pilot(Project)is to develop,implement,and
analyze a program aimed at decreasing overdose mortality prevalence and increase the
prevalence of recovery initiation by connecting individuals identified as being at high risk for
overdose with induction and engagement into Medication Assisted Treatment (MAT),
community paramedicine support,recovery support services,overdose prevention education,
and access to naloxone.
II. GOAL
Develop, implement, and analyze the efficacy of a community-based, overdose prevention
outreach pilot program in collaboration with DATA 2000 waivered practitioners, local first
responders, and certified recovery support professionals.
III. GRANTEE RESPONSIBILITIES
Grantee will:
A. Purchase and distribute supplies that aid in reducing opioid overdose risk including but
not limited to overdose reversal kits that include overdose reversal medications.
Fentanyl testing supplies may not be purchased with Contract funds.
B. Utilize the incorporated System Agency approved Attachment C, Interventional Pilot
Program model and Implementation Plan, which states the requirements for the
Emergency Medical Services(EMS) Projects services. All activities and requirements
of this Project shall be in accordance with the approved plan; any revisions shall be
submitted to the System Agency assigned contract manager for review and approval.
The requested revisions shall not be implemented until System Agency has provided
written approval of the revised plan. The approved interventional pilot model includes
the following:
1. The model will be based on the System Agency approved local needs assessment,
same day induction models, EMS follow-up models, and post-overdose reversal
recovery support services follow-up models.
2. The model will include the following basic components:
a. Working agreement with the Data 2000 Waiver certified practitioner;
b. Same-day induction on medications used to treat opioid use disorders;
c. EMS follow-up and support;
d. Recovery support services; and
e. Ensure access and delivery of Naloxone to opioid overdose survivors and any
individual identified as being high risk for opioid overdose.
3. The implementation plan will include the following basic components:
a. Patient identification and selection criteria;
b. Induction processes and protocols;
c. Linkage to Medication Assisted Therapy(MAT)processes and protocols;
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d. EMS engagement and support processes and protocols;
e. Plans and processes to ensure access to overdose reversal medication; and
f. Patient outcomes tracking system.
C. Maintain routine multi-discipline community outreach with public and private
organizations.
D. Provide and document System Agency approved trainings to community partners
on components of the pilot model. Per System Agency request, provide
documentation supporting the training to include sign-in sheets, agendas, and other
training materials.
E. Provide the services and deliverables described in this Contract in the time and manner
prescribed within the not-to-exceed amount of this Contract, as stated on Attachment
B.
F. Maintain accounting records that adequately identify and support all costs incurred
in the performance of this Contract.
G. Reporting Requirements:
Grantee will:
1. Submit documents identified in table below to the Substance Abuse mailbox at
SubstanceAbuse.Contracts(d� hhsc.state.tx.us by the required due dates.
2. Submit,on monthly basis,Patient Outcome Report on the System Agency approved
template.
3. Final Report detailing:
a. program design,
b. implementation protocols for induction, EMS follow-up, and recovery support
c. sustainability plan,
d. rates for induction,EMS follow-up, and recovery support services
e. aggregated data of prior submitted Patient Outcome Reports for that time
period, year-to-date, and over the life of the program,
ff, overdose training dates, locations, and number in attendance,
g. amount of naloxone distributed each month,
h. number of successful overdose reversals by the program and/or persons using
the naloxone they received(if data available), and
i. Successes and challenges experienced within that time period.
4. Provide System Agency annual presentation on program implementation and
outcomes.
5. Submit monthly invoices in CMBHS for cost incurred in the preceding month.
6. Submit quarterly Financial Status Report (FSR) in CMBHS for all expenses
incurred in the performance of activities within this Contract.
7. Collect, maintain, and make available upon request, documentation for all reports
required in this section of Contract as well as documentation of purchased supplies
and services.
8. Submit reports in a format approved by System Agency.
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9. If Due Date is on a weekend or holiday, the Due Date is the next business day.
Due Date Report
15th day of each month for the Item G,2 - Patient Outcome Report
duration of Project
October 15th Item G,3—Final Report
September 30'h Item G,4—Annual Presentation
The last day of the month Item G, 5 - Invoice
proceeding the month when cost
are incurred
e last day of the month following the Item G, 6-Financial Status Report
d of the quarter.The final FSR is du (FSR)
5 days after the end of the contract
term
15 Days from contract execution CMBHS Security Attestation Form and
List of Authorized Users
Within 45 days from contract execution Contract Close-out
IV.INVOICE AND PAYMENT REQUIREMENTS
Grantee will:
1. Submit monthly invoices in CMBHS for utilization of funds to support the activities
within the Attachment A. The monthly invoice shall represent the activities conducted in
the previous month. All supportive documents supporting the invoices shall be submitted
to the assigned contract manager and the Substance Abuse Contract Mailbox:
SubstanceAbuse.Contracts@hhsc.state.tx.us.
2. Submit Financial Status Reports(FSRs) in CMBHS by the last business day of the month
following the end of each quarter of the contract term. The final FSR is due within 45
days after Contract end date.
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V. CLINICAL MANAGEMENT FOR BEHAVIORAL HEALTH SERVICES
(CMBHS) SYSTEM MINIMUM REQUIREMENTS
Grantee will:
1. Designate a Security Administrator and a back-up Security Administrator. The Security
Administrator is required to implement and maintain a system for management of user
accounts/user roles to ensure that all the CMBHS user accounts are current.
2. Establish and maintain a security policy that ensures adequate system security and
protection of confidential information.
3. Notify the CMBHS Help-desk within ten (10) business days of any change to the
designated Security Administrator or the back-up Security Administrator.
4. Ensure that access to CMBHS is restricted to only authorized users. Performing Agency
shall,within 24 hours,remove access to users who are no longer authorized to have access
to secure data.
5. In addition to CMBHS Helpdesk notification, Performing Agency shall submit a signed
CMBHS Security Attestation Form and a list of Grantee's employees, contracted laborers
and subcontractors authorized to have access to secure data. The CMBHS Security
Attestation Form shall be submitted electronically within fifteen (15) days of contract
execution to the designated Substance Abuse mailbox
(SubstanceAbuse.Contracts(tbhhsc.state.tx.us).
6. Document prevention, treatment, and recovery activities and services of each
participant and/or patient in System Agency Clinical Management for Behavioral
Health Services (CMBHS) system in accordance with the Contact and instructions
provided by System Agency,unless otherwise noted.If CMBHS is unavailable,System
Agency shall provide an alternative record keeping process. Grantee shall ensure the
following:
a.Maintain all documents that require participant or staff signature in the physical record
for review by System Agency.
b. Upload documentation that is handwritten and not transcribed
into the CMBHS record.
c. Document the following in CMBHS (these data points are subject to change):
1. Client
2. Progress Note;
3. Medication Order(for patients inducted onto Buprenorphine);
4. Consent for Release of Information (including revoke consent when
appropriate);
5. Referral;
6. Performance Measures;
7. Screening(as needed);
8. Psychoeducational Note to document group education and support group
activities(as needed); and
9. Administrative Note to document any other activities(as needed).
d. Attend System Agency training on CMBHS documentation.
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ATTACHMENT A-1
STATEMENT OF WORK SUPPLEMENTAL
A. CONTRACT INFORMATION
Vendor ID: 1746017485
Grantee Name: City of Round Rock
Contract Number: HHS000508300001
Contract Type Subrecipient
Payment Method: Cost Reimbursement
DUNS Number: 10-274-0792
Federal Award Identification H79TIO81729
Number(FAIN)
Solicitation Document: Exempt: Governmental
B. SERVICE AREA:
Services or activities will be provided to participants and/or clients from the following
counties:
Statewide
C. POPULATION SERVED:
Adults—Male and Female
D. CONTACT INFORMATION
Name: Jennifer Molenaar
Email: Jennifer.molenaar hhsc.state.tx.us
Telephone: 512 206-5153
Address: 909 W 450' Street,Bldg 552 MC 2058
Cit /Zip., Austin TX 78751
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ATTACHMENT B
BUDGET
A. Funding from the United States Health and Humans Services(HHS)and the Substance
Abuse and Mental Health Services Administration (SAMSHA) for the State Targeted
Response to the Opioid Crisis Grant.
B. Match is not required using Texas Targeted Opioid Response (TTOR), State Opioid
Response(SOR) funds, CFDA number 93.788
C. Any unexpended balance associated with any other System Agency-funded contract
may not be applied to this Contract.
D. Funding
Total reimbursements will not exceed $500,000.00 for the period from May 1, 2019
through September 30,2019.
E. System Agency Share contain funds from the Texas Targeted Opioid Response(TTOR),
CFDA number 93.788.
F. Grantee is not required to contribute Match for this Contract.
G. Cost Reimbursement Budget
1. The Cost Reimbursement budget documents all approved and allowable
expenditures; Performing Agency shall only utilize the funding detailed in
Attachment B for approved and allowable costs. If Grantee requests to utilize funds
for an expense not documented on the approved budget, Grantee shall notify, in
writing,the System Agency assigned contract manager and request approval prior to
utilizing the funds. System Agency shall provide written notification regarding if the
requested expense is approved.
2. If needed, Grantee may revise the System Agency approved Cost Reimbursement
budget. The requirements are as follows:
a. Grantee is allowed to transfer funds from the budgeted direct categories only;
with the exception of the Equipment Category. Grantee may transfer up to ten
(10)percent of the Fiscal Year Contract value without System Agency approval.
Budget revisions exceeding the ten percent requirement require System
Agency's written approval.
b. Grantee may request revisions to the approved Cost Reimbursement budgeted
direct categories that exceed the ten(10)percent requirement stated in(G)(2)(a),
by submitting a written request to the Assigned contract manager. This change
is considered a minor administrative change and does not require an amendment.
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The System Agency shall provide written notification if the budget revision is
approved; and the assigned Contract Manager will update CMBHS, as needed.
c. Grantee may revise the Cost Reimbursement budget`Equipment' and/or`Indirect
Cost' Categories, however a formal Amendment is required. Grantee shall
submit to the assigned contract manager a written request to revise the budget,
which includes a justification for the revisions. The assigned Contract Manager
shall provide written notification stating if the requested revision is approved. If
the revision is approved, the budget revision is not authorized and funds cannot
be utilized until the Amendment is executed and signed by both parties.
3. The budgeted indirect cost amount is provisional and subject to change. The System
Agency reserves the right to negotiate Grantee's indirect cost amount, which may
require Grantee to provide additional supporting documentation to the assigned
contract manager.
H. The FY2019 budget information is as follows:
1. The 2019 budget are as follows:
PERSONNEL $0.00
FRINGE BENEFITS $0.00
TRAVEL $0.00
EQUIPMENT $0.00
SUPPLIES $250,000.00
CONTRACTUAL $250,000.00
OTHER $0.00
TOTAL DIRECT CHARGES $500,000.00
INDIRECT CHARGES $0.00
TOTAL $500,000.00
SYSTEM AGENCY SHARE $0.00
MATCH $0.00
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ATTACHMENT C
INTERVENTIONAL PILOT PROGRAM MODEL AND IMPLEMENTATION PLAN
HHSC/TTOR
RESPONSE TO EMS TASK TRACKER QUESTIONS
ROUND ROCK FIRE DEPARTMENT
TASK ONE NEEDS ASSESSMENT
The Williamson County Mobile Outreach Team provides emergency behavioral health and
crisis response services to the citizens of Williamson County. Since 2004 The Mobile Outreach
Team (MOT) has served clients diagnosed with Substance Abuse Disorder and their families
during times of crisis. It is our role to assess the situation and refer consumers to the most
appropriate treatment available. It has always been a challenge to find treatment and recovery
resources in our County, especially for uninsured persons. In 2015 and 2016 the team noted an
increase in call volume related to heroin use and heroin overdoses and responded to a handful of
families whose family members had died due to overdose. We found it difficult to provide
accessible resources to this group of consumers and began exploring innovative or alternative
methods for assisting this population. In August of 2016, representatives from MOT met Mark
Kinzly of the Texas Overdose Naloxone Initiative (TONI) at the 1 st annual Williamson County
Overdose Awareness Day. Mr. Kinzly immediately became a remarkable resource for MOT,
especially in terms of helping patients access treatment.Mr.Kinzly supplied Daniel Sledge(MOT
Paramedic)with a few doses of IM naloxone in August 2016. Shortly thereafter,the MOT Director
and Mr. Sledge met with the Williamson County EMS medical director, Dr. Jarvis, who offered
approval and support for distribution of take-home naloxone to patients at risk of overdose. In
September 2016, MOT made contact with an individual with Opioid Use Disorder in the process
of release from incarceration and distributed the first dose of take-home naloxone. The team
provided onthe-spot training to the patient and a friend.
It was around this time that two medics, Julie Lahr and Anna Sessa, met with Mr. Sledge
to discuss ideas on how to effectively identify patients at risk of opioid overdose and connect them
to overdose education and naloxone distribution(OEND)via MOT. The three medics decided to
try to run EMS reports identifying patients who were administered naloxone by EMS.EMS Medic
Kirsti Elias set up the report generator for MOT to use to identify target patients.
Between emergency behavioral health calls, Mr. Sledge ran naloxone reports on ESO(the
EMS electronic medical record) and attempted to make contact with patients identified as being
at-risk for opioid overdose. If successful at making contact and the patient consented, Mr. Sledge
provided OEND to patients and any loved ones present. Additionally, Mr. Sledge used
motivational interviewing techniques to engage them in patient-led conversations about reducing
harm and promoting any positive change.This included sometimes linking patients to services for
Substance Use Disorder, behavioral health, and medical care, as well as linking patients and
families to peer support and mutual aid groups.
Mark Kinzly donated to MOT additional doses of IM naloxone, as well as doses of Evzio
by Kaleo, Amphastar prefilled syringes with Intranasal Mucosal Atomization Devices, and
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fentanyl testing strips. During the period (September 2016 through March 2018), there were no
other services in Williamson County providing OEND to patients at risk of opioid overdose and
their loved ones. MOT noted during these encounters that there was little or no knowledge of
naloxone—how to use it or how to obtain it. MOT served approximately 15 families between
September 2016 and March 2018.
Representation: To determine who was most at risk for overdose,MOT once again turned
to EMS records for data and discovered that 41% of the overdoses in the county over the past 11
months occurred in the Round Rock area. An overview of 111 patient records showed that male
adults were experiencing overdoses at a higher rate than females. Please see Wilco EMS overdose
map and note that this does not include data from Georgetown Fire Department and therefore
excludes the Georgetown area.
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TASKS TWO and THREE
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INTERVENTION AND IMPLEMENTATION PLAN
Patients are identified by 911/EMS/FD First Responders during an opioid overdose call. If the
patient is medically clear to forego transport to an emergency department, the responding EMS
Medic Unit requests an MM Unit(Medic and Mental Health Specialist)to join the active call for
service. The MM unit then arrives,assesses the patient,offers treatment if indicated,and provides
a rescue kit and training if appropriate.
If the patient is transported to an Emergency Department by EMS, the clinical assessment, offer
of treatment, and naloxone rescue kit will be offered to the patient at the Emergency Department
or on a follow-up visit to the home by the team within 7 days after the initial overdose.
If the patient meets criteria for Opioid Use Disorder and has no other acute medical needs, the
patient is offered Medication Assisted Treatment(MAT)and Peer Support Services. If the patient
is not interested in treatment or recovery supports, the MM team requests permission to continue
to followup with the patient in an attempt to engage the patient in recovery and support services
over time.
If the patient chooses to access MAT, the MM team contacts the Data Waived MAT physician at
the Williamson County and Cities Health District(WCCHD)or a private provider with immediate
intake availability. If the patient is enrolled with a private provider, the MM Team will transfer
care and followup with the patient if requested by both the provider and the patient. If the patient
is uninsured or unable to access care, the MM Team and the WCCHD physician review the
patient's medical and substance use history, and the physician determines if lab work is indicated.
If so, the MM unit transports the patient to an approved lab and then to WCCHD for additional
medical assessment and discussion of MAT induction. The goal is to provide same-day induction
to buprenorphine if at all possible.
Once at WCCHD,the patient is met by the MAT Data Waived physician and support staff. During
this visit a medical history is obtained and the patient is examined. If there are any acute medical
needs discovered during this exam, the patient is referred out to the most appropriate medical
provider. If not, MAT, symptoms and risks of withdrawal, the follow-up process, and the plan
for ongoing care are fully explained to the patient and consent is obtained. The physician, the
patient,and the MM Team then review the induction process and timing of the first MAT dose and
the prescription is given to the patient. It is anticipated that most patients will be prescribed
buprenorphine. The MM Team then transports the patient to the pharmacy and if needed,
purchases the medication using Williamson County Emergency Services flex funding. The patient
is then transported home with a clear plan of induction, knowledge of the Clinical Opiate
Withdrawal Scale (COWS), and how to contact the team with questions or concerns. Any social
service,behavioral health,or minor medical needs are also addressed or discussed. A Peer Support
Specialist is introduced during this process and ideally will meet with the team and the patient
during this stage of intervention. If not during the initial intervention or induction, then as soon
as possible.
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All instructions for MAT are reviewed by the patient and when medically appropriate(according
to COWS),the fust dose of medication is ingested. The MM team then follows-up with the patient
face-to face every day until the patient is medically stable (as determined by the WCCHD
physician in concert with the MM Paramedic). The team may employ telemedicine to
communicate with the WCCHD physician and may also bring the patient to the clinic if needed.
The Paramedic is responsible for checking the patient's vital signs,monitoring the patient for signs
and symptoms of complicated withdrawal, and communicating daily with the WCCHD physician.
The Peer Support Specialist provides support and access to community-based services throughout
this process and is available by phone or text around the clock. The Mental Health Specialist
provides crisis counseling, referrals for behavioral health care, and facilitates access to social
services and benefits. Because this is a new treatment model for WCCHD physician, she may
obtain consultation from a national MAT subject matter expert to review protocols and dosages on
a case by case basis. Dr. Jarvis,the Medical Director for Williamson County Emergency Medical
Services, will provide medical oversight for the Paramedics providing MAT follow-up services.
Please see attached COWS Scale for reference.
Once the patient has stabilized,the team turns its efforts to facilitating admission to long-term care,
preferably to an Office-Based Opioid Treatment(OBOT)center. The MM Team and Peer Support
Specialist are tasked with shepherding the patient through the oftentimes complex and frustrating
SUD treatment admission process and will provide emotional and logistical support throughout.
After the patient is enrolled in and successfully attending long-term care, the MM Team meets
with the patient with less frequency and discharges the patient when all involved (the WCCHD
physician, the patient, the MM Team, and the Peer Support Specialist) agree that transfer of care
is complete. The patient understands that he or she may contact the team for reengagement if
needed.
MAT SYSTEM OF CARE
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INTERVENTION PLAN OUTLINE
All patients and their loved-ones,family members,friends,and/or roommates are offered naloxone
rescue kits which include gloves,CPR mask, instructions,resource materials,and fentanyl testing
strips if available,and overdose response training whether they enroll in treatment services or not.
The MM Team will run EMS naloxone and overdose reports each week in addition to responding
to 911 overdose calls to ensure that patients are contacted and offered services and rescue
medication. The MM Team will provide home/field visits to patients to provide naloxone rescue
kits. At least once a month during the grant period,the team will participate in community events
to provide outreach, overdose response training, and rescue kits to the community at large. The
team will also collaborate with all area first responder agencies, local prevention and intervention
organizations, recovery groups, schools, and hospitals to coordinate the distribution of overdose
reversal medication. Round Rock Fire Department will also provide education to all First
Responder Advanced Providers regarding Substance Use Disorder and opioid overdose response.
The goal is to support harm reduction at all levels of intervention and engagement.
PATIENT OUTCOMES
The MM Team will track the number of
• patients offered overdose rescue kits and training
• patients assessed for Opioid Use Disorder
• patients offered Medication Assisted Treatment
• patients enrolled in Medication Assisted Treatment
• patients offered Peer Recovery Services
• patients enrolled in Peer Recovery Services
• patients enrolled in long term treatment
• rate of overdose post MM Team involvement for all patient groups(enrolled or assessed)
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HHSC Uniform Terms and Conditions Version 2.14
Published and Effective:September 1,2017
Responsible Office:Chief Counsel
�JJv
TEVAS
Health and Human Services
Health and Human Services Commission
HHSC Uniform Terms and Conditions -
Local Governmental Body
Version 2.14
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TABLE OF CONTENTS
ARTICLE I DEFINITIONS AND INTERPRETIVE PROVISIONS............................................3
1.01 Definitions..........................................................................................................................3
1.02 Interpretive Provisions.....................................................................................................4
ARTICLE II CONSIDERATION...................................................................................................5
2.01 Expenses...........................................................................................................................5
2.02 Funding.............................................................................................................................5
ARTICLE III WARRANTY,AFFIRMATIONS,ASSURANCES AND CERTIFICATIONS....6
3.01 Federal Assurances...........................................................................................................6
3.02 Federal Certifications.......................................................................................................6
ARTICLE IV INTELLECTUAL PROPERTY..............................................................................6
4.01 Intellectual Property.........................................................................................................6
ARTICLE V RECORDS,AUDIT,AND DISCLOSURE.............................................................6
5.01 Access to records,books,and documents........................................................................6
5.02 Response/compliance with audit or inspection findings..................................................7
5.03 SAO Audit........................................................................................................................7
5.04 Recapture of Funds...........................................................................................................7
5.05 Public Information and Confidentiality............................................................................8
5.06 Data Security....................................................................................................................8
ARTICLE VI CONTRACT MANAGEMENT AND EARLY TERMINATION.........................8
6.01 Contract Management......................................................................................................8
6.02 Termination for Convenience...........................................................................................8
6.03 Termination for Cause......................................................................................................9
6.04 Equitable Settlement........................................................................................................9
ARTICLE VII MISCELLANEOUS PROVISIONS......................................................................9
7.01 Technical Guidance Letters..............................................................................................9
7.02 Survivability.....................................................................................................................9
7.03 No Waiver........................................................................................................................9
7.04 Standard Terms and Conditions.......................................................................................9
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ARTICLE I DEFINITIONS AND INTERPRETIVE PROVISIONS
1.01 Definitions
As used in this Contract,unless the context clearly indicates otherwise or defined in the Signature
Document,the following terms and conditions have the meanings assigned below:
"Amendment"means a written agreement,signed by the parties hereto,which documents changes
to the Contract other than those permitted by Technical Guidance Letters,as herein defined.
"Attachment"means documents,terms,conditions,or additional information physically added to
this Contract following the execution page or inchided by reference, as if physically, within the
body of this Contract.
"Contract"means the Signature Document,these Uniform Terms and Conditions,along with any
Attachments,and any Amendments, purchase orders,or Technical Guidance Letters that may be
issued by the System Agency,to be incorporated by reference herein for all purposes if issued.
"Deliverables"means any item,report,data,document,photograph,or other submission required to
be delivered under the terms of this Contract,in whatever form.
"Effective Date"means the date agreed to by the Parties as the date on which the Contract takes
effect.
"Federal Assurances" means Standard Form 424B (Rev. 7-97), as prescribed by OMB
Circular A-102 (non-construction projects); or Standard Form 424D (Rev. 7-97), as
prescribed by OMB Circular A-102(construction projects).
"Federal Certifications" means U.S. Department of Commerce Form CD-512 (12-04),
"Certifications Regarding Lobbying—Lower Tier Covered Transactions."
"Federal Fiscal Year"means the period beginning October 1 and ending September 30 each year,
which is the annual accounting period for the United States government.
"GAAP"means Generally Accepted Accounting Principles.
"GASB"means the Governmental Accounting Standards Board.
"Health and Human Services Commission" or `TMSC" means the administrative agency
established under Chapter 531,Texas Government Code or its designee.
"Intellectual Property'means patents,rights to apply for patents,trademarks,trade names,service
marks, domain names, copyrights and all applications and worldwide registration of such,
schematics,industrial models, inventions,know-how,trade secrets,computer software programs,
and other intangible proprietary information.
"Local Government"means the Party to this Contract that meets the definition of this term under
Tex.Gov't Code§791.003(4).
"Parties"means the System Agency and Local Government,collectively.
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'Tarty"means either the System Agency or Performing Agency,individually.
"Project'means the goods and/or Services described in the Signature Document or an Attachment
to this Contract
"Public Information Act"or"PI.A"means Chapter 552 of the Texas Goverment Code.
"Services" means the tasks, functions, and responsibilities assigned and delegated to Local
Goverment under the Contract
"Signature Document"means the document executed by both Parties that specifically sets forth all
of the documents that constitute the Contract.
"System Agency" means HHSC or any of the agencies of the State of Texas that are
overseen by HHSC under authority granted under State law and the officers, employees,
and designees of those agencies. These agencies include: HHSC and the Department of
State Health Services.
"State Fiscal "ear"means the period beginning September 1 and ending August 31 each year,
which is the annual accounting period for the State of Texas.
"State of Texas Te_-dmveP' means Texas Administrative Code, Title 34, Part 1, Chapter 5,
Subchapter C,Section 5.22,relative to travel reimbursements under this Contract,if any.
"Subcontractor"means an individual or business that performs part or all of the obligations
of Local Government under this Contract.
"Technical Guidance Letter"or"TGL"means an instruction,clarification,or interpretation of the
requirements of the Contract,issued by the System Agency to the Local Government.
"Mor "means all Services to be performed,goods to be delivered,and any appurtenant actions
performed and items produced,conceived,or developed,including Deliverables.
1.02 Interpretive Provisions
A. The meanings of defined terms are equally applicable to the singular and plural forms of the
defined terms.
B. The words "hereof,""herein,""hereunder,"and similar words refer to this Contract as a
whole and not to any particular provision,section,Attachment,or schedule of this Contract
unless otherwise specified
C. The tern"including"is not limiting and means `Including without limitation"and,unless
otherwise expressly provided in this Contract, (i) references to contracts (including this
Contract) and other contractual instruments shall be deemed to include all subsequent
Amendments and other modifications thereto,but only to the extent that such Amendments
and other modifications are not prohibited by the terms of this Contract,and(u)references to
any statute or regulation are to be construed as including all statutory and regulatory
provisions consolidating,amending,replacing, supplementing,or interpreting the statute or
regulation.
D. Any references to "sections," "appendices," or "attachments" are references to sections,
appendices,or attachments of the Contract
E. Any references to agreements,contracts,statutes,or administrative rules or regulations in the
Contract are references to these documents as amended,modified,or supplemented from time
to time during the term of the Contract.
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F. The captions and headings of this Contract are for convenience of reference only and shall
not affect the interpretation of this Contract.
G. All Attachments within this Contract, including those incorporated by reference, and any
Amendments are considered part of the terms of this Contract.
H. This Contract may use several different limitations,regulations, or policies to regulate the
same or similar matters. All such limitations,regulations,and policies are cumulative and
each shall be performed in accordance with its terms.
I. Unless otherwise expressly provided,reference to any action of the System Agency or by the
System Agency by way of consent, approval, or waiver shall be deemed modified by the
phrase`5n its sole discretion."
J. Time is of the essence in this Contract.
ARTICLE 1I CONSIDERATION
2.01 Expenses
Except as otherwise provided in the Contract, no ancillary expenses incurred by the Local
Government in connection with its provision of the Services or Deliverables will be reimbursed by
the System Agency. Ancillary expenses include, but are not limited to costs associated with
transportation,delivery,and insurance for each Deliverable.
When the reimbursement of travel expenses is authorized by the Contract,all such expenses shall
be reimbursed in accordance with the rates set by the State of Texas TeAlravel.
2.02 Funding
A. This Contract shall not be construed as creating any debt on behalf of the State of Texas
or the System Agency in violation of Article III,Section 49,of the Texas Constitution.
In compliance with Article VIII, Section 6 of the Texas Constitution, it is understood
that all obligations of the System Agency hereunder are subject to the availability of
state funds. If such funds are not appropriated or become unavailable,this Contract may
be terminated. In that event,the Parties shall be discharged from finther obligations,
subject to the equitable settlement of their respective interests,accrued up to the date of
termination
B. Furthermore,any claim by Local Government for damages under this Contract may not
exceed the amount of funds appropriated for payment, but not yet paid to Local
Government,under the annual budget in effect at the time of the breach. Nothing in
this provision shall be construed as a waiver of sovereign immunity.
C. This Contract is contingent upon the availability of sufficient and adequate funds. If
funds become unavailable through lack of appropriations, budget cuts, transfer of
funds between programs or agencies, amendment of the Texas General
Appropriations Act,agency consolidation,or any other disruptions of current funding
for this Contract,the System Agency may restrict,reduce,or terminate funding under
this Contract. This Contract is also subject to immediate cancellation or termination,
without penalty to the System Agency, if sufficient and adequate funds are not
available. Contractor will have no right of action against the System Agency if the
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System Agency cannot perforin its obligations under this Contract as a result of lack
of funding for any activities or functions contained within the scope of this Contract.
In the event of cancellation or termination under this Section, the System Agency
shall not be required to give notice and shall not be liable for any damages or losses
caused or associated with such termination or cancellation.
ARTICLE III WARRANTY,AFFIRMATIONS,ASSURANCES AND CERTIFICATIONS
3.01 Federal Assurances
Local Government further certifies that,to the extent Federal Assurances are incorporated into the
Contract under the Signature Document,the Federal Assurances have been reviewed and that Local
Government is in compliance with each of the requirements reflected therein.
3.02 Federal Certifications
Local Government further certifies,to the extent Federal Certifications are incorporated into the
Contract under the Signature Document,that the Federal Certifications have been reviewed,and
that Local Government is in compliance with each of the requirements reflected therein. In
addition, Local Government certifies that it is in compliance with all applicable federal laws,
rules,or regulations,as they may pertain to this Contract
ARTICLE IV INTELLECTUAL PROPERTY
4.01 Intellectual Property
A. To the extent any Work results in the creation of Intellectual Property, all right, title, and
interest in and to such Intellectual Property shall vest in the System Agency upon creation and
shall be deemed to be a`work made for hire"and made in the course of the services rendered
pursuant to this Contract.
B. To the extent that title to any such Intellectual Property may not by law vest in the System
Agency,or such Intellectual Property may not be considered a`work made for hire,"all rights,
title,and interest therein are hereby irrevocably assigned to the System Agency. The System
Agency shall have the right to obtain and to hold in its name any and all patents,copyrights,
trademarks,service marks,registrations,or such other protection as may be appropriate to the
subject matter,including extensions and renewals thereof.
C. Local Government must give the System Agency and the State of Texas,as well as any person
designated by the System Agency or the State of Texas,all assistance required to perfect the
rights defined herein without any charge or expense beyond the stated amount payable to Local
Government for the services authorized under this Contract
ARTICLE V RECORDS,AUDIT,AND DISCLOSURE
5.01 Access to records,books,and documents
In addition to any right of access arising by operation of law,Local Government and any of Local
Government's affiliate or subsidiary organizations, or Subcontractors shall permit the System
Agency or any of its duly authorized representatives,as well as duly authorized federal,state or
local authorities, unrestricted access to and the right to examine any site where business is
conducted or Services are performed,and all records,which includes but is not limited to financial,
client and patient records,books, papas or documents related to this Contract If the Contract
includes federal funds,federal agencies that shall have a right of access to records as described in
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this section include:the federal agency providing the fimds,the Comptroller General of the United
States, the General Accounting Office, the Office of the Inspector General, and any of their
authorized representatives. In addition,agencies of the State of Texas that shall have a right of
access to records as described in this section include: the System Agency, HHSC, HHSC's
contracted examiners, the State Auditor's Office, the Texas Attorney General's Office, and any
successor agencies. Each of these entities may be a duly authorized authority. If deemed necessary
by the System Agency or any duly authorized authority,for the purpose of investigation or hearing,
Local Government shall produce original documents related to this Contract. The System Agency
and any duly authorized authority shall have the right to audit billings both before and after
payment,and all documentation that substantiates the billings. Local Government shall include this
provision concerning the right of access to,and examination of,sites and information related to this
Contract in any Subcontract it awards.
5.02 Response/compliance with audit or inspection findings
A. At Local Government's sole expense, Local Government must take action to ensure its or a
Subcontractor's compliance with a correction of any finding of noncompliance with any law,
regulation, audit requirement, or generally accepted accounting principle relating to the
Services and Deliverables or any other deficiency contained in any audit,review,or inspection
conducted under the Contract.Whether Local Government's action corrects the noncompliance
shall be solely the decision of the System Agency.
B. As part of the Services,Local Government must provide to HHSC upon request a copy of those
portions of Local Government's and its Subcontractors' internal audit reports relating to the
Services and Deliverables provided to the State under the Contract.
5.03 SAO Audit
Local Government understands that acceptance of funds directly under the Contract or indirectly
through a Subcontract under the Contract acts as acceptance of the authority of the State Auditor's
Office(SAO), or any successor agency,to conduct an audit or investigation in connection with
those funds.Under the direction of the legislative audit committee,an entity that is the subject of an
audit or investigation by the SAO must provide the SAO with access to any information the SAO
considers relevant to the investigation or audit Local Government agrees to cooperate fully with
the SAO or its successor in the conduct of the audit or investigation,including providing all records
requested. Local Government will ensure that this clause concerning the authority to audit funds
received indirectly by Subcontractors through Local Government and the requirement to cooperate
is included in any Subcontract it awards.
5.04 Recapture of Funds
The System Agency may withhold all or part of any payments to Local Government to offset
overpayments made to the Local Government Overpayments as used in this Section include
payments(i)made by the System Agency that exceed the maximum allowable rates;(ii)that are not
allowed under applicable laws,rules,or regulations;or(iii)that are otherwise inconsistent with this
Contract,including any unapproved expenditures. Local Government understands and agrees that it
shall be liable to the System Agency for any costs disallowed pursuant to financial and compliance
audit(s)of fiords received under this Contract Local Government further understands and agrees
that reimbursement of such disallowed costs shall be paid by Local Government from funds which
were not provided or otherwise made available to Local Government under this Contract.
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5.05 Public Information and Confidentiality
Information related to the performance of this Contract may be subject to the Public
Information Act and will be withheld from public disclosure or released to the public only in
accordance therewith. Local Government shall make any information required under the
Public Information Act available to the System Agency in portable document file C'.pdf
format or any other format agreed between the Parties.
To the extent permitted by law, Local Government and the System Agency agree to keep
all information confidential,in whatever form produced,prepared,observed,or received by
Local Government or the System Agency. The provisions of this section remain in full
force and effect following termination or cessation of the services performed under this
Contract.
5.06 Data Security
Each Party and its Subcontractors will maintain reasonable and appropriate administrative,
physical,and technical safeguards to ensure the integrity and confidentiality of information
exchanged in the performance of services pursuant to this Contract and protect against any
reasonably anticipated threats or hazards to the security or integrity of the information and
unauthorized use or disclosure of the information in accordance with applicable federal and
state laws,rules,and regulations.
Upon notice, either Party will provide,or cause its subcontractors and agents to provide,
the other Party or its designee prompt access to any information security records,books,
documents,and papers that relate to services provided under this Contract.
ARTICLE VI CONTRACT MANAGEMENT AND EARLY TERMINATION
6.01 Contract Management
To ensure full performance of the Contract and compliance with applicable law, the System
Agency may take actions including:
A. suspending all or part of the Contract;
B. requiring the Local Government to take specific corrective actions in order to remain in
compliance with tern of the Contract;
C. recouping payments made to the Local Government found to be in error;
D. suspending and/or limiting any services and placing conditions on any such suspensions
and/or limitations of services;
E. imposing any other remedies authorized under this Contract;and
F. imposing any other remedies, sanctions or penalties permitted by federal or state
statute,law,regulation,rule.
6.02 Termination for Convenience
The System Agency may terminate the Contract at any time when,in its sole discretion,the System
Agency determines that termination is in the best interests of the State of Texas. The termination
will be effective on the date specified in HHSC's notice of termination.
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6.03 Termination for Cause
The System Agency will have the right to terminate the Contract in whole or in part if the
System Agency determines, at its sole discretion, that Local Government has materially
breached the Contract or has failed to adhere to any laws,ordinances,rules,regulations or
orders of any public authority having jurisdiction and such violation prevents or
substantially impairs performance of Local Government's duties under the Contract
604 Equitable Settlement
Any early termination under this Article shall be subject to the equitable settlement of the
respective interests of the Parties up to the date of termination.
ARTICLE VII MISCELLANEOUS PROVISIONS
7.01 Technical Guidance Letters
In the sole discretion of the System Agency,and in conformance with federal and state law,the
System Agency may issue instructions,clarifications,or interpretations as may be required during
Work performance in the form of a Technical Guidance Letter. A TGL must be in writing and
may be delivered by regular mail.electronic mail,or facsimile transmission. Any TGL issued by
the System Agency shall be incorporated into the Contract by reference herein for all purposes
when it is issued.
7.02 Survivability
All obligations and duties of the Local Government not fully performed as of the expiration or
termination of this Contract will survive the expiration or termination of the Contract.
7.03 No Waiver
Neither failure to enforce any provision of this Contract nor payment for services provided under it
constitute waiver of any provision of the Contract.
7.04 Standard Terms and Conditions
A. In the performance of this Contract,each Party shall comply with all applicable federal,
state,and local laws,ordinances,and regulations. Each Party shall make itself familiar
with and at all times shall observe and comply with all federal, state, and local laws,
ordinances,and regulations that in any manner affect performance under this Contract
Each Party will be deemed to have knowledge of all applicable laws and regulations
and be deemed to understand them.
B. All records relevant to this Contract shall be retained for a minimum of seven(7)years.
The period of retention begins at the date of final payment by the System Agency, or
from the date of termination of the Contract,whichever is later. The period of retention
shall be extended for a period reasonably necessary to complete an audit or to complete
any administrative proceeding or litigation that may ensue.
C. The System Agency shall own, and Local Government hereby assigns to the System
Agency,all right,title,and interest in all tangible Work.
D. Local Government shall keep and maintain under GAAP or GASB, as applicable,full,
true, and complete records necessary to fully disclose to the System Agency,the Texas
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State Auditor's Office, the United States Government, and/or their authorized
representatives sufficient information to determine compliance with the terms and
conditions of this Contract and all state and federal Hiles,regulations,and statutes.
E. This Contract and the rights and obligations of the Parties hereto shall be governed by,
and construed according to,the laws of the State of Texas,exclusive of conflicts of law
provisions. Venue of any suit brought under this Contract shall be in a court of
competent jurisdiction in Travis County,Texas. Local Goverment irrevocably waives
any objection,including any objection to personal jurisdiction or the laying of venue or
based on the grounds of forum non conveniens,which it may now or hereafter have to
the bringing of any action or proceeding in such jurisdiction in respect of this Contract
or any document related hereto. NOTHING IN THIS SECTION SHALL BE CONSTRUED AS
A WAIVER OF SOVEREIGN IMMUNITY BY THE SYSTEM AGENCY.
F. If any provision contained in this Contract is held to be unenforceable by a court of law
or equity,this Contract shall be construed as if such provision did not exist and the non-
enforceability of such provision shall not be held to render any other provision or
provisions of this Contract unenforceable.
G. Except with respect to the obligation of payments under this Contract, if either of the
Parties,after a good faith effort,is prevented from complying with any express or implied
covenant of this Contract by reason of war, terrorism; rebellion; riots; strikes; acts of
God;any valid order,rule,or regulation of governmental authority;or similar events that
are beyond the control of the affected Party (collectively referred to as a "Force
Majeure'),then,while so prevented,the affected Party's obligation to comply with such
covenant shall be suspended, and the affected Party shall not be liable for damages for
failure to comply with such covenant. In any such event, the Party claiming Force
Majeure shall promptly notify the other Party of the Force Majeure event in writing and,
if possible,such notice shall set forth the extent and duration thereof. The Party claiming
Force Majeure shall exercise due diligence to prevent,eliminate,or overcome such Force
Majeure event where it is possible to do so and shall resume performance at the earliest
possible date. However,if non-performance continues for more than thirty(30)days,the
System Agency may terminate this Contract immediately upon written notification to
Local Government.
H. This Contract,its integrated Attachment(s),and any purchase order issued in conjunction
with this Contract constitute the entire agreement of the Parties and are intended as a
complete and exclusive statement of the promises, representations, negotiations,
discussions, and other agreements that may have been made in connection with the
subject matter hereof. Any additional or conflicting terms in such Attachment(s)and/or
purchase order shall be harmonized with this Contract to the extent possible. Unless such
integrated Attachment or purchase order specifically displays a mutual intent to amend a
particular part of this Contract, general conflicts in language shall be construed
consistently with the terms of this Contract
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I. Neither party shall assign or subcontract the whole nor any part of the contract,
including any right or duty required under it, without the other party's prior written
consent. Any assignment made contrary to this shall be void.
J. This Contract may be executed in any number of counterparts,each of which shall be
an original, and all such counterparts shall together constitute but one and the same
Contract. If the Contract is not executed by the System Agency within thirty(30)days
of execution by the other Party,this Contract shall be null and void.
K. Pursuant to Chapter 2259 of the Texas Government Code entitled, "Self-Insurance by
Governmental Units," Each Party is self-insured and, therefore, is not required to
purchase insurance.
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Attachment E
Special Conditions
ioTEv,,A-,S
, - Health and Human Services
Health and Human Services Commission
Special Conditions
Version 1.1
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TABLE OF CONTENTS
ARTICLEI. Special Definitions................................................................................................30
ARTICLE II. Grantees Personnel and Subcontractors ........................................................32
2.01 Qualifications.....................................................................................................................32
2.02 Conduct and Removal .......................................................................................................32
ARTICLEIII. Confidentiality.................................................................................................32
3.01 Confidential System Information...................................................................................... 32
ARTICLE IV. Miscellaneous Provisions................................................................................33
4.01 Conflicts of Interest........................................................................................................... 33
4.02 Flow Down Provisions...................................................................................................... 34
ARTICLE V.DSHS Legacy Provisions......................................................................................34
5.01 Notice of Criminal Activity and Disciplinary Actions............................................
5.02 Notice of IRS or TWC Insolvency....................................................................................35
5.03 Education to Persons in Residential Facilities...................................................................35
5.04 Disaster Services................................................................................................................35
5.05 Consent by Non-Parent or Other State Law to Medical Care of a Minor......................... 36
5.06 Telemedicine/Telepsychiatry Medical Services............................................................... 36
5.07 Services and Information for Persons with Limited English Proficiency......................... 37
5.08 Third Parry Payors............................................................................................................. 37
5.09 HIV/AIDS Model Workplace Guidelines......................................................................... 38
5.10 Medical Records Retention............................................................................................... 38
5.11 Notice of a License Action................................................................................................38
5.12 Interim Extension Amendment.......................................................................................... 38
5.13 Child Abuse Reporting Requirement.................................Error! Bookmark not defined.
5.14 Grantee's Certification of Meeting or Exceeding Tobacco-Free Workplace Policy
Minimum Standards ...................................................................Error! Bookmark not defined.
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HHSC SPECIAL CONDITIONS
The terms and conditions of these Special Conditions are incorporated into and made a part of the
Contract. Capitalized items used in these Special Conditions and not otherwise defined have the
meanings assigned to them in HHSC Grantee Uniform Terms and Conditions--Version 2.14
ARTICLE I. SPECIAL DEFINITIONS
"Conflict of Interest" means a set of facts or circumstances, a relationship, or other situation
under which Grantee, a Subcontractor, or individual has past, present, or currently planned
personal or financial activities or interests that either directly or indirectly: (1) impairs or
diminishes the Grantee's, or Subcontractor's ability to render impartial or objective assistance or
advice to the HHSC;or(2)provides the Grantee or Subcontractor an unfair competitive advantage
in future HHSC procurements.
"Grantee Agents"means Grantee's representatives,employees,officers,as well as any contractor
or subgrantee's employees,contractors,officers,principals and agents.
"Custom Software" means Software developed as a Deliverable or in connection with the
Agreement.
"Data Use Agreement"means the agreement incorporated into the Contract to facilitate creation,
receipt,maintenance,use, disclosure or access to Confidential Information.
"Federal Financial Participation" is a program that allows states to receive partial
reimbursement for activities that meet certain objectives of the federal government. It is also
commonly referred to as the Federal Medical Assistance Percentage(FMAP).
"Item of Noncompliance" means Grantee's acts or omissions that: (1) violate a provision of the
Contract; (2) fail to ensure adequate performance of the Project; (3)represent a failure of Grantee
to be responsive to a request of HHSC relating to the Project under the Contract.
"Minor Administrative Change" refers to a change to the Contract that does not increase the
fees or term and done in accordance with Section Section 4.01 of these Special Conditions.
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"Confidential System Information" means any communication or record(whether oral,written,
electronically stored or transmitted,or in any other form)provided to or made available to Grantee;
or that Grantee may create, receive, maintain, use, disclose or have access to on behalf of HHSC
or through performance of the Project, which is not designated as Confidential Information in
aData Use Agreement.
"State" means the State of Texas and, unless otherwise indicated or appropriate, will be
interpreted to mean HHSC and other agencies of the State of Texas that may participate in the
administration of HHSC Programs; provided, however, that no provision will be interpreted to
include any entity other than HHSC as the contracting agency.
"Software" means all operating system and applications software used or created by Grantee to
perform the work under the Contract.
"Third Party Software" refers to software programs or plug-ins developed by companies or
individuals other than Grantee which are used in performance of the Project. It does not include
items which are ancillary to the performance of the Project, such as internal systems of Grantee
which were deployed by Grantee prior to the Contract and not procured to perform the Project.
"UTC" means HHSC's Uniform Terms and Conditions—Local Government Body- Version 2.14
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ARTICLE II.GRANTEES PERSONNEL
Section 2.01 QUALIFICATIONS
Grantee agrees to maintain the organizational and administrative capacity and capabilities
proposed in its response to the Solicitation,as modified,to carry out all duties and responsibilities
under the Contract. Grantee Agents assigned to perform the duties and responsibilities under the
Contract must be and remain properly trained and qualified for the functions they are to perform.
Notwithstanding the transfer or turnover of personnel, Grantee remains obligated to perform all
duties and responsibilities under the Contract without degradation and in strict accordance with
the terms of the Contract.
Section 2.02 CONDUCT AND REMOVAL
While performing the Project, Grantee Agents must comply with applicable Contract terms, State
and federal rules, regulations, HHSC's policies, and HHSC's requests regarding personal and
professional conduct; and otherwise conduct themselves in a businesslike and professional
manner.
If HHSC determines in good faith that a particular Grantee Agent is not conducting himself or
herself in accordance with the terms of the Contract,HHSC may provide Grantee with notice and
documentation regarding its concerns. Upon receipt of such notice, Grantee must promptly
investigate the matter and, at HHSC's election,take appropriate action that may include removing
the Grantee Agent from performing the Project.
ARTICLE III. CONFIDENTIALITY
Section 3.01 CONFIDENTIAL SYSTEM INFORMATION
HHSC prohibits the unauthorized disclosure of Other Confidential Information. Grantee and all
Grantee Agents will not disclose or use any Other Confidential Information in any manner except
as is necessary for the Project or the proper discharge of obligations and securing of rights under
the Contract. Grantee will have a system in effect to protect Other Confidential Information. Any
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disclosure or transfer of Other Confidential Information by Grantee, including information
requested to do so by HHSC,will be in accordance with the Contract. If Grantee receives a request
for Other Confidential Information, Grantee will immediately notify HHSC of the request, and
will make reasonable efforts to protect the Other Confidential Information from disclosure until
further instructed by the HHSC.
Grantee will notify HHSC promptly of any unauthorized possession, use, knowledge, or attempt
thereof,of any Other Confidential Information by any person or entity that may become known to
Grantee. Grantee will furnish to HHSC all known details of the unauthorized possession, use, or
knowledge, or attempt thereof, and use reasonable efforts to assist HHSC in investigating or
preventing the reoccurrence of any unauthorized possession,use,or knowledge,or attempt thereof,
of Other Confidential Information.
HHSC will have the right to recover from Grantee all damages and liabilities caused by or arising
from Grantee or Grantee Agents' failure to protect HHSC's Confidential Information as required
by this section.
IN COORDINATION WITH THE INDEMNITY PROVISIONS
CONTAINED IN THE UTC, Grantee WILL INDEMNIFY AND HOLD
HARMLESS HHSC FROM ALL DAMAGES, COSTS, LIABILITIES, AND
EXPENSES (INCLUDING WITHOUT LIMITATION REASONABLE
ATTORNEYS' FEES AND COSTS) CAUSED BY OR ARISING FROM
Grantee OR Grantee AGENTS FAILURE TO PROTECT OTHER
CONFIDENTIAL INFORMATION. Grantee WILL FULFILL THIS
PROVISION WITH COUNSEL APPROVED BY HHSC.
ARTICLE IV. MISCELLANEOUS PROVISIONS
Section 4.01 MINOR ADMINISTRATIVE CHANGES
HHSC's designee,referred to as the Contract Manager,Project Sponsor,or other equivalent,in the
Contract,is authorized to provide written approval of mutually agreed upon Minor Administrative
Changes to the Project or the Contract that do not increase the fees or term. Changes that increase
the fees or term must be accomplished through the formal amendment procedure, as set forth in
the UTC. Upon approval of a Minor Administrative Change, HHSC and Grantee will maintain
written notice that the change has been accepted in their Contract files.
Section 4.02 CONFLICTS OF INTEREST
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Grantee warrants to the best of its knowledge and belief, except to the extent already disclosed to
HHSC,there are no facts or circumstances that could give rise to a Conflict of Interest and further
that Grantee or Grantee Agents have no interest and will not acquire any direct or indirect interest
that would conflict in any manner or degree with their performance under the Contract. Grantee
will, and require Grantee Agents, to establish safeguards to prohibit Contract Agents from using
their positions for a purpose that constitutes or presents the appearance of personal or
organizational Conflict of Interest, or for personal gain. Grantee and Grantee Agents will operate
with complete independence and objectivity without actual, potential or apparent Conflict of
Interest with respect to the activities conducted under the Contract.
Grantee agrees that, if after Grantee's execution of the Contract, Grantee discovers or is made
aware of a Conflict of Interest,Grantee will immediately and fully disclose such interest in writing
to HHSC. In addition, Grantee will promptly and fully disclose any relationship that might be
perceived or represented as a conflict after its discovery by Grantee or by HHSC as a potential
conflict. HHSC reserves the right to make a final determination regarding the existence of
Conflicts of Interest, and Grantee agrees to abide by HHSC's decision.
If HHSC determines that Grantee was aware of a Conflict of Interest and did not disclose the
conflict to HHSC, such nondisclosure will be considered a material breach of the Contract.
Furthermore, such breach may be submitted to the Office of the Attorney General, Texas Ethics
Commission, or appropriate State or federal law enforcement officials for further action.
Section 4.03 FLOW DOWN PROVISIONS
Grantee must include any applicable provisions of the Contract in all subcontracts based on the
scope and magnitude of work to be performed by such Subcontractor. Any necessary terms will
be modified appropriately to preserve the State's rights under the Contract.
ARTICLE V. DSHS LEGACY PROVISIONS
Section 5.01 NOTICE OF CRIMINAL ACTIVITY AND DISCIPLINARY ACTIONS
(a) Grantee shall immediately report in writing to their contract manager when Grantee
has knowledge or any reason to believe that they or any person with ownership or
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controlling interest in the organization/business, or their agent, employee,
subcontractor or volunteer that is providing services under this Contract has:
Engaged in any activity that could constitute a criminal offense equal to or greater than a
Class A misdemeanor or grounds for disciplinary action by a state or federal regulatory
authority;or
Been placed on community supervision, received deferred adjudication, or been indicted
for or convicted of a criminal offense relating to involvement in any financial matter,
federal or state program or felony sex crime.
(b) Grantee shall not permit any person who engaged,or was alleged to have engaged,in
any activity subject to reporting under this section to perform direct client services or
have direct contact with clients, unless otherwise directed in writing by the System
Agency.
Section 5.02 NOTICE OF IRS OR TWC INSOLVENCY
Grantee shall notify in writing their assigned contract manager their insolvency, incapacity or
outstanding unpaid obligations to the Internal Revenue Service (IRS) or Texas Workforce
Commission within five days of the date of becoming aware of such.
Section 5.03 EDUCATION TO PERSONS IN RESIDENTIAL FACILITIES
Grantee shall ensure that all persons, who are housed in System Agency licensed or funded
residential facilities and are 22 years of age or younger, have access to educational services as
required by Texas Education Code § 29.012.
Grantee shall notify the local education agency or local early intervention program as prescribed
by this Section not later than the third calendar day after the date a person who is 22 years of age
or younger is placed in Grantee's residential facility
Section 5.04 DISASTER SERVICES
In the event of a local, state, or federal emergency, including natural, man- made, criminal,
terrorist, and/or bioterrorism events, declared as a state disaster by the Governor, or a federal
disaster by the appropriate federal official, Grantee may be called upon to assist the System
Agency in providing the following services:
a. Community evacuation;
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b. Health and medical assistance;
c. Assessment of health and medical needs;
d. Health surveillance;
e. Medical care personnel;
f. Health and medical equipment and supplies;
g. Patient evacuation;
h. In-hospital care and hospital facility status;
i. Food,drug and medical device safety;
j. worker health and safety;
k. Mental health and substance abuse;
1. Public health information;
m. Vector control and veterinary services; and
n. Victim identification and mortuary services.
Section 5.05 CONSENT BY NON-PARENT OR OTHER STATE LAW TO MEDICAL CARE OF A
MINOR
Unless a federal law applies, before a Grantee or its subcontractor can provide medical, dental,
psychological or surgical treatment to a minor without parental consent,informed consent must be
obtained as required by Texas Family Code Chapter 32.
Section 5.06 TELEMEDICINE/TELEPSYCHIATRY MEDICAL SERVICES
If Grantee or its subcontractor uses telemedicine/telepsychiatry, these services shall be in
accordance with the Grantee's written procedures. Grantee must use a protocol approved by
Grantee's medical director and equipment that complies with the System Agency equipment
standards,if applicable. Grantee's procedures for providing telemedicine service must include
the following requirements:
a. Clinical oversight by Grantee's medical director or designated physician responsible
for medical leadership;
b. Contraindication considerations for telemedicine use;
c. Qualified staff members to ensure the safety of the individual being served by
telemedicine at the remote site;
d. Safeguards to ensure confidentiality and privacy in accordance with state and federal laws;
e. Use by credentialed licensed providers providing clinical care within the scope of their
licenses;
f. Demonstrated competency in the operations of the system by all staff members who are
involved in the operation of the system and provision of the services prior to initiating
the protocol;
g. Priority in scheduling the system for clinical care of individuals;
h. Quality oversight and monitoring of satisfaction of the individuals served; and
i. Management of information and documentation for telemedicine services that ensures
timely access to accurate information between the two sites. Telemedicine Medical
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Services does not include chemical dependency treatment services provided by
electronic means under 25 Texas Administrative Code Rule§ 448.911.
Section 5.07 SERVICES AND INFORMATION FOR PERSONS WITH LIMITED ENGLISH
PROFICIENCY
a. Grantee shall take reasonable steps to provide services and information both orally and
in writing, in appropriate languages other than English, to ensure that persons with
limited English proficiency are effectively informed and can have meaningful access to
programs,benefits and activities.
b. Grantee shall identify and document on the client records the primary language/dialect
of a client who has limited English proficiency and the need for translation or
interpretation services and shall not require a client to provide or pay for the services of
a translator or interpreter.
c. Grantee shall make every effort to avoid use of any persons under the age of 18 or any
family member or friend of the client as an interpreter for essential communications
with a client with limited English proficiency unless the client has requested that person
and using the person would not compromise the effectiveness of services or violate the
client's confidentiality and the client is advised that a free interpreter is available.
Section 5.08 THI12D PARTY PAYORS
Except as provided in this Contract, Grantee shall screen all clients and may not bill the System
Agency for services eligible for reimbursement from third party payors,who are any person or entity
who has the legal responsibility for paying for all or part of the services provided, including
commercial health or liability insurance carriers,Medicaid,or other federal, state, local and private
funding sources.
As applicable,the Grantee shall:
a. Enroll as a provider in Children's Health Insurance Program and Medicaid if providing
approved services authorized under this Contract that may be covered by those programs
and bill those programs for the covered services;
b. Provide assistance to individuals to enroll in such programs when the screening process
indicates possible eligibility for such programs;
c. Allow clients that are otherwise eligible for System Agency services, but cannot pay a
deductible required by a third party payor, to receive services up to the amount of the
deductible and to bill the System Agency for the deductible;
d. Not bill the System Agency for any services eligible for third party reimbursement until all
appeals to third party payors have been exhausted;
e. Maintain appropriate documentation from the third party payor reflecting
attempts to obtain reimbursement;
f. Bill all third party payors for services provided under this Contract before submitting any
request for reimbursement to System Agency; and
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g. Provide third party billing functions at no cost to the client.
Section 5.09 HIV/AIDS MODEL WORKPLACE GUIDELINES
Grantee shall implement System Agency's policies based on the Human Immunodeficiency
Virus/Acquired Immunodeficiency Syndrome(HIV/AIDS),AIDS Model Workplace Guidelines
for Businesses at http://www.dshs.state.tx.us/hivstd:policy/policies.shtm, State Agencies and
State Grantees Policy No. 090.021.
Grantee shall also educate employees and clients concerning HIV and its related conditions,
including AIDS, in accordance with the Texas. Health&Safety Code §§ 85.112-114.
Section 5.10 MEDICAL RECORDS RETENTION
Grantee shall retain medical records in accordance with 22 TAC §165.1(b) or other applicable
statutes, rules and regulations governing medical information.
Section 5.11 NOTICE OF A LICENSE ACTION
Grantee shall notify their contract manager of any action impacting its license to provide services
under this Contract within five days of becoming aware of the action and include the following:
a. Reason for such action;
b. Name and contact information of the local,state or federal department or agency or entity;
c. Date of the license action; and
d. License or case reference number.
Section 5.12 INTERIM EYTENSION AMENDMENT
a. Prior to or on the expiration date of this Contract,the Parties agree that this Contract can
be extended as provided under this Section.
b. The System Agency shall provide written notice of interim extension amendment to the
Grantee under one of the following circumstances:
1. Continue provision of services in response to a disaster declared by the governor; or
2. To ensure that services are provided to clients without interruption.
c. The System Agency will provide written notice of the interim extension amendment that
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specifies the reason for it and period of time for the extension.
d. Grantee will provide and invoice for services in the same manner that is stated in the
Contract.
e. An interim extension under Section (b)(1) above shall extend the term of the contract
not longer than 30 days after governor's disaster declaration is declared unless the Parties
agree to a shorter period of time.
f. An interim extension under Section(b)(2) above shall be a one-time extension for
a period of time determined by the System Agency.
Section 5.13 NOTICE OF CONTRACT ACTION
Grantee ("Performing Agency","Contractor") shall notify their assigned contract manager if
Performing Agency has had any contract suspended or terminated for cause by any local, state or
federal department or agency or nonprofit entity within five days of becoming aware of the
action and include the following:
a. Reason for such action;
b.Name and contact information of the local, state or federal department or agency or entity;
c. Date of the contract;
d. Date of suspension or termination; and
e. Contract or case reference number.
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
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CERTIFICATION REGARDING LOBBYING
Certification for Contracts,Grants,Loans,and Cooperative Agreements
The undersigned certifies,to the best of his or her knowledge and belief,that:
(1)No Federal appropriated funds have been paid or will be paid,by or on behalf of the undersigned,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.
(2)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 outer 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 undersigned shall complete and submit Standard
Form-LLL,"Disclosure of Lobbying Activities."in accordance with its instructions.
(3)The undersigned 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 shall certify and disclose accordingly.This certification
is a material representation of fact upon which reliance was placed when this transaction was made or
entered into.Submission of this certification is a prerequisite for making or entering into this transaction
imposed by section 1352,title 31,U.S.Code.Any person who fails to file the required certification shall be
subject to a civil penalty of not less then$10,000 and not more than$100,000 for each such failure.
Statement for Loan Guarantees and Loan Insurance
The undersigned states,to the best of his or her knowledge and belief,that:
If any 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 commitment providing for the United States to insure or
guarantee a loan,the undersigned shall complete and submit Standard Form-LLL,"Disclosure of Lobbying
Activities,"in accordance with its instructions.Submission of this statement is a prerequisite for making or
entering into this transaction imposed by section 1352,title 31,U.S.Code.Any person who fails to file the
required statement shall be subject to a civil penalty of not less then$10,000 and not more than$100,000
for each such failure.
APPLICANTS ORGANIZATION
•PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE
Prefix: •First Neme: O e et Middle Name:
Last Name: Suffix
rifle:
•SIGNATURE F 'DATE:
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View Burden Statement OMB Number.4040.0007
Expiration Date:01/312019
ASSURANCES-NON-CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 15 minutes per response,including time for reviewing
instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of
information.Send comments regarding the burden estimate or any other aspect of this collection of information,including suggestions for
reducing this burden,to the Office of Management and Budget,Paperwork Reduction Project(0348-0040),Washington,DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND
IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
NOTE: Certain of these assurances may not be applicable to your projector program.If you have questions,please contact the
awarding agency.Further,certain Federal awarding agencies may require applicants to certify to additional assurances.
If such is the case,you will be notified.
As the duly authorized representative of the applicant,I certify that the applicant
1. Has the legal authority to apply for Federal assistance Act of 1973,as amended(29 U.S.C.§794),which
and the institutional,managerial and financial capability prohibits discrimination on the basis of handicaps;(d)
(including funds sufficient to pay the non-Federal share the Age Discrimination Act of 1975,as amended(42 U.
of project cost)to ensure proper planning,management S.C.§§6101-6107),which prohibits discrimination on
and completion of the project described in this the basis of age;(e)the Drug Abuse Office and
application. Treatment Act of 1972(P.L.92-255),as amended,
relating to nondiscrimination on the basis of drug
2. Will give the awarding agency,the Comptroller General abuse;(f)the Comprehensive Alcohol Abuse and
of the United States and,if appropriate,the State, Alcoholism Prevention,Treatment and Rehabilitation
through any authorized representative,access to and Act of 1970(P.L.91-616),as amended, relating to
the right to examine all records,books,papers,or nondiscrimination on the basis of alcohol abuse or
documents related to the award;and will establish a alcoholism(g)§§523 and 527 of the Public Health
proper accounting system in accordance with generally Service Act of 1912(42 U.S.C.§§290 dd-3 and 290
accepted accounting standards or agency directives. ee-3),as amended,relating to confidentiality of alcohol
and drug abuse patient records;(h)Title VIII of the Civil
3. Will establish safeguards to prohibit employees from Rights Act of 1968(42 U.S.C.§§3601 et seq.),as
using their positions for a purpose that constitutes or amended,relating to nondiscrimination in the sale,
presents the appearance of personal or organizational rental or financing of housing;(i)any other
conflict of interest,or personal gain. nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being
4. Will initiate and complete the work within the applicable made;and,(l1 the requirements of any other
time frame after receipt of approval of the awarding nondiscrimination statute(s)which may apply to the
agency. application.
5. Will comply with the Intergovernmental Personnel Act of 7. Will comply,or has already complied,with the
requirements of Titles II and III of the Uniform
1970(42 U.S.C.§§4728-4763)relating to prescribed Relocation Assistance and Real Property Acquisition
standards for merit systems for programs funded under
Policies Act to le treatment
(P.L.91-646)which provide for
one of the 19 statutes or regulations specified in
fair and equitable treatment of persons displaced or
Appendix A of OPM's Standards for a Merit System of whose property is acquired as a result of Federal or
Personnel Administration(5 C.F.R.900,Subpart F). federally-assisted programs.These requirements
6. Will comply with all Federal statutes relating to apply to all interests in real property acquired far
project purposes regardless of Federal participation in
nondiscrimination.These include but are not limited to: purchases.
(a)Title VI of the Civil Rights Act of 1964(P.L.88-352)
which prohibits discrimination on the basis of race,color 8. Will comply,as applicable,with provisions of the
or national origin;(b)Title IX of the Education Hatch Act(5 U.S.C.§§1501-1508 and 7324-7328)
Amendments of 1972,as amended(20 U.S.C.§§1681- which limit the political activities of employees whose
1683, and 1685-1686),which prohibits discrimination on principal employment activities are funded in whole
the basis of sex;(c)Section 504 of the Rehabilitation or in part with Federal funds.
Previous Edition Usable Standard Form 424B(Rev.7-97)
Authorized for Local Reproduction Prescribed by OMB Circular A-102
System Agency Contract No.HHS000508300001 Page 41 of 64
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9. Will comply,as applicable,with the provisions of the Davis- 13. Will assist the awarding agency in assuring compliance
Bacon Act(40 U.S.C.§§276a to 276a-7),the Copeland Act with Section 106 of the National Historic Preservation
(40 U.S.C.§276c and 18 U.S.C.§874),and the Contract Act of 1966,as amended(16 U.S.C.§470),EO 11593
Work Hours and Safety Standards Act(40 U.S.C.§§327- (identification and protection of historic properties),and
333),regarding labor standards for federally-assisted the Archaeological and Historic Preservation Act of
construction subagreements. 1974 16 U.S.C.
10. Will comply,if applicable,with flood insurance purchase 14. Will comply with P L.93-348 regarding the protection of
requirements of Section 102(a)of the Flood Disaster human subjects involved in research,development,and
Protection Act of 1973(P.L.93-234)which requires related activities supported by this award of assistance.
recipients in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of 15. Will comply with the Laboratory Animal Welfare Act of
insurable construction and acquisition is$10,000 or more. 1966(P.L.89-544,as amended,7 U.S.C.§§2131 et
seq.)pertaining to the care,handling,and treatment of
11. Will comply with environmental standards which may be warm blooded animals held for research,teaching,or
prescribed pursuant to the following:(a)institution of other activities supported by this award of assistance,
environmental quality control measures under the National
Environmental Policy Act of 1969(P.L.91-190)and 16. Will comply with the Lead-Based Paint Poisoning
Executive Order(EO)11514;(b)notification of violating Prevention Act(42 U.S.C.§§4801 et seq.)which
facilities pursuant to EO 11738,(c)protection of wetlands prohibits the use of lead-based paint in construction or
pursuant to EO 11990,(d)evaluation of flood hazards in rehabilitation of residence structures.
floodplain in accordance with EO 11988;(e)assurance of 17 Will cause to be performed the required financial and
project consistency with the approved State management compliance audits in accordance with the Single Audit
program developed under the Coastal Zone Management Act Amendments of 1996 and OMB Circular No.A-133,
Act of 1972(16 U.S.C.§§1451 et seq.);(f)conformity of "Audits of States,Local Governments,and Non-Profit
Federal actions to State(Clean Air)Implementation Plans Organizations."
under Section 176(c)of the Clean Air Act of 1955,as
amended(42 U.S.C.§§7401 et seq.);(g)protection of 18. WII comply with all applicable requirements of all other
underground sources of drinking water under the Safe Federal laws,executive orders,regulations,and policies
Drinking Water Act of 1974,as amended(P L.93-523); governing this program.
and,(h)protection of endangered species under the
Endangered Species Act of 1973,as amended(P.L.93- 19. Will comply with the requirements of Section 106(g)of
205). the Trafficking Victims Protection Act(rVPA)of 2000,as
12. Will comply with the Wild and Scenic Rivers Act of amended(22 U.S.C.7104)which prohibits grant award
recipients or a sub-recipient from(1)Engaging in severe
1968(16 U.S.C.§§1271 et seq.)related to protecting forms of trafficking in persons during the period of time
components or potential components of the national that the award is in effect(2)Procuring a commercial
wild and scenic rivers system. sex act during the period of time that the award is in
effect or(3)Using forced labor in the performance of the
award or subawards under the award.
'SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
APPLICANT ORGANIZATION DATE SUBMITTED
Standard Fonn 4246(Rev.797)Back
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...._._....._
DATA USE AGREEMENT
BETWEEN THE
TEXAS HEALTH AND HUMAN SERVICES SYSTEM
AND
CONTRACTOR
This Data Use Agreement("DUA')is effective as of the date of the Base Contract into which it is
incorporated("Effective Date'),by and between the Texas Health and Human Services System,which
includes the Texas Health and Human Services Commission and the Department of State Health Services
and Contractor(the'Base Contract').
ARTICLE 1. PURPOSE; APPLICABILITY; ORDER OF PRECEDENCE
The purpose of this DUA is to facilitate access to,creation,receipt,maintenance,use,disclosure or transmission
of Confidential Information with Contractor,and describe Contractor's rights and obligations with respect to
the Confidential Information and the limited purposes for which the Contractor may create,receive,maintain,
use,disclose or have access to Confidential Information. This DUA also describes HHS's remedies in the
event of Contractor's noncompliance with its obligations under this DUA. This DUA applies to both HHS
business associates,as"business associate"is defined in the Health Insurance Portability and Accountability
Act((Ill[PAA),and contractors who are not business associates,who create,receive,maintain,use,disclose or
have access to Confidential Information on behalf of HHS,its programs or clients as described in the Base
Contract As a best practice,HHS requires its contractors to comply with the terms of this DUA to safeguard
all types of Confidential Information.
As of the Effective Date of this DUA,if any provision of the Base Contract conflicts with this DUA,
this DUA controls.
ARTICLE 2. DEFINITIONS
For the purposes of this DUA,capitalized,underlined terms have the following meanings:
"Authorized Purpose"means the specific purpose or purposes described in the Base Contract for Contractor
to fulfill its obligations under the Base Contract,or any other purpose expressly authorized by HHS in writing
in advance.
"Authorized User"means a person:
(1) Who is authorized to create, receive, maintain, have access to, process, view, handle,
examine,interpret,or analyze Confidential Information pursuant to this DUA;
(2) For whom Contractor warrants and represents has a demonstrable need to create,receive,
maintain,use,disclose or have access to the Confidential Information and
(3) Who has agreed in writing to be bound by the disclosure and use limitations pertaining to
the Confidential Information as required by this DUA.
"Breach"means an impermissible use or disclosure of electronic or non-electronic sensitive personal
information by an unauthorized person or for an unauthorized purpose that compromises the security or
privacy of Confidential Information such that the use or disclosure poses a risk of reputational hamr,theft
of financial information,identity theft,or medical identity theft.Any acquisition,access,use,disclosure or
loss of Confidential Information other than as permitted by this DUA shall be presumed to be a Breach
unless Contractor demonstrates, based on a risk assessment, that there is a low probability that the
Confidential Information has been compromised.
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"Confidential Information"means any communication or record(whether oral,written,electronically stored
or transmitted,or in any other form)provided to or made available to Contractor or that Contractor may create,
receive,maintain,use,disclose or have access to on behalf of HHS that consists of or includes any or all of the
following:
(1) Education records as defined in the Family Educational Rights and Privacy Act,20 U.S.C.
§12328;34 C.F.R.Part 99
(2) Federal Tax Information as defined in Internal Revenue Code§6103 and Internal Revenue
Service Publication 1075;
(3) Personal Identifying Information(PH)as defined in Texas Business and Commerce Code,
Chapter 521;
(4) Protected Health Information(PHI)in any form including without limitation,Electronic
Protected Health Information or Unsecured Protected Health Information as defined in 45
C.F.R.§160.103;
(5) Sensitive Personal Information(SPI)as defined in Texas Business and Commerce Code,
Chapter 521;
(6) Social Security Administration Data,including,without limitation,Medicaid information
means disclosures of information made by the Social Security Administration or the Centers for Medicare
and Medicaid Services from a federal system of records for administration of federally funded benefit
programs under the Social Security Act,42 U.S.C.,Chapter 7;
(7) All privileged work product;
(8) All information designated as confidential under the constitution and laws of the State of
Texas and of the United States,including the Texas Health&Safety Code and the Texas Public Information
Act,Texas Government Code,Chapter 552.
"Destroy","Destruction",for Confidential Information.means:
(1) Paper,film, or other hard copy media have been shredded or destroyed such that the
Confidential Information cannot be read or otherwise cannot be reconstructed. Redaction is specifically
excluded as a means of data destruction.
(2) Electronic media have been cleared,purged,or destroyed consistent with NIST Special
Publication 800-88,"Guidelines for Media Sanitization."such that the Confidential Information cannot be
retrieved.
"Discover. Discovery" means the first day on which a Breach becomes known to Contractor, or, by
exercising reasonable diligence would have been known to Contractor.
"Leeally Authorized Representative"of an individual,including w provided in 45 CFR 435.923(authorized
representative);45 CFR 164.502(g)(1)(personal representative);Tex.Oce.Code§151.002(6);Teat.H &S.
Code§166.164(medical power of attomeyr and Texas Estates Code§22.031(representative).
"Required by Law"means a mandate contained in law that compels an entity to use or disclose Confidential
Information that is enforceable in a court of law,including court orders,warrants,subpoenas or investigative
demands.
"Subcontractor"means a person who contracts with a prime contractor to work,to supply commodities,or to
contribute toward completing work for a governmental entity.
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"Workforce"means employees,volunteers,trainees or other persons whose performance of work is under the
direct control of a party,whether or not they are paid by that party.
ARTICLE 3.CONTRACTOR'S DUTIES REGARDING CONFIDENTIAL INFORMATION
Section 3.01 Oblieations of Contractor
Contractor agrees that:
(A) With respect to PHI,Contractor shall:
(1) Make PHI available in a designated record set if requested by HHS,if Contractor maintains
PHI in a designated record set,as defined in HIPAA.
(2) Provide to HHS data aggregation services related to the healthcare operations Contractor
performs for HHS pursuant to the Base Contract, if requested by HHS, if Contractor provides data
aggregation services as defined in HIPAA.
(3) Provide access to PER to an individual who is requesting his or her own PHL or such
individual's Le¢ally Authorized Representative,in compliance with the requirements of HIPAA.
(4) Make PHI available to HHS for amendment,and incorporate any amendments to PHI that
HHS directs,in compliance with HIPAA.
(5) Document and make available to HHS,an accounting of disclosures in compliance with
the requirements of HIPAA.
(6) If Contractor receives a request for access, amendment or accounting of PHI by any
individual,promptly forward the request to HHS or, if forwarding the request would violate H1P�AE
promptly notify HHS of the request and of Contractor's response. HHS will respond to all such requests,
unless Contractor is&&pined by Law to respond or HHS has given prior written consent for Contractor to
respond to and account for all such requests.
(B) With respect to ALL Confidential Information.Contractor shall:
(1) Exercise reasonable care and no less than the same degree of care Contractor uses to protect
its own confidential,proprietary and trade secret information to prevent Confidential Information from
being used in a manner that is not expressly an Authorized Purpose or as Required by Law.Contractor will
access,create,maintain,receive,use,disclose,transmit or Destroy Confidential Information in a secure
fashion that protects against any reasonably anticipated threats or hazards to the security or integrity of
such information or unauthorized uses.
(2) Establish, implement and maintain appropriate procedural,administrative,physical and
technical safeguards to preserve and maintain the confidentiality, integrity, and availability of the
Confidential Information in accordance with applicable laws or regulations relating to Confidential
Information. to prevent any unauthorized use or disclosure of Confidential Information as long as
Contractor has such Confidential Information in its actual or constrictive possession.
(3) Implement,update as necessary,and document privacy,security and Breach notice policies
and procedures and an incident response plan to address a Breac to comply with the privacy,security and
breach notice requirements of this DUA prior to conducting work under the Base Contract. Contractor
shall produce,within three business days of a request by HHS,copies of its policies and procedures and
records relating to the use or disclosure of Confidential Information.
(4) Obtain HHS's prior written consent to disclose or allow access to any portion of the
Confidential Information to any person, other than Authorized Users. Workforce or Subcontractors of
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Contractor who have completed training in confidentiality,privacy,security and the importance of promptly
reporting any Breach to Contractor's management and as permitted in Section 3.01(Ax3), above.
Contractor shall produce evidence of completed training to HHS upon request. HHS,at its election,may
assist Contractor in training and education on speck or unique HHS processes, systems and/or
requirements.
(5) Establish, implement and maintain appropriate sanctions against any member of its
Workforce or Subcontractor who fails to comply with this DUA,the Base Contract or applicable law.
Contractor shall maintain evidence of sanctions and produce it to HHS upon request.
(6) Obtain prior written approval of HHS,to disclose or provide access to any Confidential
Information on the basis that such act is Required by Law,so that HHS may have the opportunity to object
to the disclosure or access and seek appropriate relief. If HHS objects to such disclosure or access,
Contractor shall refrain from disclosing or providing access to the Confidential Information until HHS has
exhausted all alternatives for relief.
(7) Certify that its Authorized Users each have a demonstrated need to know and have access
to Confidential Information solely to the minimum extent necessary to accomplish the Authorized Purpose
and that each has agreed in writing to be bound by the disclosure and use limitations pertaining to the
Confidential Information contained in this DUA. Contractor and its Subcontractors shall maintain at all
times an updated,complete,accurate list of Authorized Users and supply it to HHS upon request.
(8) Provide,and shall cause its Subcontractors and agents to provide,to HHS periodic written
confirmation of compliance with controls and the terms and conditions of this DUA.
(9) Return to HHS or Destroy,at HHS's election and at Contractor's expense,all Confidential
Information received from HHS or created or maintained by Contractor or any of Contractor's agents or
Subcontractors on HHS's behalf upon the termination or expiration of this DUA,if reasonably feasible and
permitted by law. Contractor shall certify in writing to HHS that all such Confidential Information has
been Destroyed or returned to HHS,and that Contractor and its agents and Subcontractors have retained no
copies thereof. Notwithstanding the foregoing,Contractor acknowledges and agrees that it may not Destroy
any Confidential Information if federal or state law,or HHS record retention policy or a litigation hold
notice prohibits such Destruction. If such return or Destruction is not reasonably feasible, or is
impermissible by law,Contractor shall immediately notify HHS of the reasons such return or Destruction
is not feasible,and agree to extend the protections of this DUA to the Confidential Information for as long
as Contractor maintains such Confidential Information.
(10) Complete and return with the Base Contract to HHS,attached as Attachment 2 to this DUA,
the HHS Security and Privacy Initial Inquiry (SPI) at haps://hhs.teraegov/lar
regaladons/jormsInuceelkneous/hhs-information-securioN privackiaidal-*uo,Wspi The SPI
identifies basic privacy and security controls with which Contractor must comply to protect Confidential
Information. Contractor shall comply with periodic security controls compliance assessment and
monitoring by HHS as required by state and federal law,based on the type of Confidential Information
Contractor creates,receives,maintains,uses,discloses or has access to and the Authorized Purpose and level
of risk. Contractor's security controls shall be based on the National Institute of Standards and Technology
(NIST)Special Publication 800-53. Contractor shall update its security controls assessment whenever there
are significant changes in security controls for HHS Confidential Information and shall provide the updated
document to HHS. HHS also reserves the right to request updates as needed to satisfy state and federal
monitoring requirements.
(11) Comply with the HHS Acceptable Use Policy(AUP)and require each Subcontractor and
Workforce member who has direct access to HHS Information Resources,as defined in the AUT,to execute
an HHS Acceptable Use Agreement
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(12) Only conduct secure transmissions of Confidential Information whether in paper,oral or
electronic form A secure transmission of electronic Confidential Information in motion includes secure
File Transfer Protocol(SFTP)or encryption at an appropriate level as required by rule,regulation or law.
Confidential Information at rest requires encryption unless there is adequate administrative,technical,and
physical security as required by rule,regulation or law. All electronic data transfer and communications of
Confidential Information shall be through secure systems.Contractor shall provide proof of system,media
or device security and/or encryption to HHS no later than 48 hours after HHS's written request in response
to a compliance investigation,audit,or the Discovery of a Breach. HHS may also request production of
proof of security at other times as necessary to satisfy state and federal monitoring requirements. De-
identification of Confidential Information in accordance with HIPAA de-identification standards is deemed
secure.
(13) Designate and identify a person or persons,as Privacy Official and Information Security
Oficial,each of whom is authorized to act on behalf of Contractor and is responsible for the development
and implementation of the privacy and security requirements in this DUA. Contractor shall provide name
and current address,phone number and e-mail address for such designated officials to HHS upon execution
of this DUA and prior to any change. Upon written notice from HHS,Contractor shall promptly remove
and replace such official(s)if such official(s)is not perforating the required functions.
(14) Make available to HHS any information HHS requires to fulfill HHS's obligations to provide
access to,or copies of Confidential Information in accordance with applicable laws,regulations or demands
of a regulatory authority relating to Confidential Information. Contractor shall provide such information in a
time and manner reasonably agreed upon or as designated by the applicable law or regulatory authority.
(15) Comply with the following laws and standards if applicable to the type of Confidential
Infotnralion and Contrador's As ahorized Purpose
• Title 1,Part 10•Chapter 202,Subchapter B-Texas Administrative Code;
• The Privacy Act of 1974;
• OMB Memorandum 17-12;
• The Federal Information Security Management Act of 2002(FISMA);
• The Health Insurance Portability and Accountability Act of 1996(HIP ;
• Internal Revenue Publication 1075—Tax Information Security Guidelines for Federal, State
and Local Agencies;
• National Institute of Standards and Technology(NIST)Special Publication 800-66 Revision 1
— An Introductory Resource Guide for Implementing the Health Insurance Portability and
Accountability Act(HIPAA)Security Rule;
• NIST Special Publications 800-53 and 800-53A—Recommended Security Controls for Federal
Information Systems and Organizations,as currently revised;
• NIST Special Publication 800-47 — Security Guide for Interconnecting Information
Technology Systems;
• NIST Special Publication 800-88,Guidelines for Media Sanitization:
• NIST Special Publication 800-111,Guide to Storage of Encryption Technologies for End User
Devices containing EL-
• Family Educational Rights and Privacy Act
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• Any other State or Federal law,regulation,or administrative rule relating to the specific HHS
program area that Contractor supports on behalf of HHS.
(16) Be permitted to use or disclose Confidential Information for the proper management and
administration of Contractor or to carry out Contractor's legal responsibilities,except as otherwise
limited by this DUA,the Base Contractor law applicable to the Confidential Information,if:
(a) Disclosure is Required by Law;
(b) Contractor obtains reasonable assurances from the person to whom the information is
disclosed that the person shall:
1. Maintain the confidentiality of the Confidential Information in accordance with
this DUA;
2. Use or further disclose the information only as Required by Law or for the
Authorized Purpose for which it was disclosed to the person;and
3. Notify Contractor in accordance with Section 4.01 of a Breach of Confidential
Information that the person Discovers or should have Discovered with the exercise of
reasonable diligence.
(C) With respect to ALL Confidential Information,Contractor shall NOT:
(1) Attempt to re-identify or further identify Confidential Information that has been de-
identified,or attempt to contact any persons whose records are contained in the Confidential Information.
except for an Authorized Purpose,without express written authorization from HISS.
(2) Engage in prohibited marketing or sale of Confidential Information.
(3) Permit,or enter into any agreement with a Subcontractor to,create,receive,maintain,use,
disclose,have access to or transmit Confidential Informationon behalf of HHS without requiring that
Subcontractor first execute either the Form Subcontractor Agreement,Attachment 1,or Contractor's own
Subcontractor agreement that ensures that the Subcontractor shall comply with the same safeguards and
restrictions contained in this DUA for Confidential Information. Contractor is directly responsible for its
Subcontractors'compliance with,and enforcement of,this DUA.
ARTICLE 4. BREACH NOTICE,REPORTING AND CORRECTION REQUIREMENTS
Section 4.01. Cooperation and Financial Responsibility.
(A) Contractor shall, at Contractor's expense, cooperate fully with HHS in investigating,
mitigating to the extent practicable, and issuing notifications as directed by HHS, for any Breach of
Confidential Information.
(B) Contractor shall make Confidential Information in Contractor's possession available
pursuant to the requirements of HIPAA or other applicable law upon a determination of a Breach.
(C) Contractor's obligation begins at the Discovery of a Breach and continues as long
as related activity continues,until all effects of the Breach are mitigated to HHS's satisfaction(the
"incident response period").
Section 4.02. Initial Breach Notice.
For federal information obtained from a federal system of records,including Federal Tax Information and
Social Security Administration Data(which includes Medicaid and other governmental benefit program
Confidential Information),Contractor shall notify HISS of the Breach within the fust consecutive clock
hour of Discovery. The Base Contract shall specify whether Confidential Information is obtained from a
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federal system of records. For all other types of Confidential Information Contractor shall notify HHS of
the Breach not more than 24 hours after Discovery, or in a fimeframe oNrowim approved by HHS in
writing. Contractor shall initially report to HHS's Privacy and Security Officers via email at:
privacy[I-II-ISC.state.tx.us and to the HHS division responsible for the Base Contract.
Contractor shall report all information reasonably available to Contractor about the Breach.
Contractor shall provide contact information to HHS for Contractor's single point of contact who will
communicate with HHS both on and off business hours during the incident response period.
Section 4.03 Third Business Day Notice: No later than 5 p.m. on the third business day after
Discovery,or a time within which Discovery reasonably should have been made by Contractor of a Breach
of Confidential Information Contractor shall provide written notification to HHS of all reasonably available
information about the Br eac and Contractor's investigation,including,to the extent known to Contractor:
a.The date the Breach occurred;
b.The date of Contractor's and,if applicable,Subcontractor's Discovery;
c. A brief description of the Bre ac including how it occurred and who is responsible (or
hypotheses,if not yet determined);
d.A brief description of Contractor's investigation and the status of the investigation;
e. A description of the types and amount of Confidential Information involved;
f.Identification of and number of all individuals reasonably believed to be affected,including fust
and last name of the individual and if applicable,the Legally authorized representative,last known
address,age,telephone number,and email address if it is a preferred contact method;
g.Contractor's initial risk assessment of the Breach demonstrating whether individual or other
notices are required by applicable law or this DUA for HHS approval,including an analysis of
whether there is a low probability of compromise of the Confidential Information or whether any
legal exceptions to notification apply-,
h.Contractor's recommendation for HHS's approval as to the steps individuals and/or Contractor
on behalf of individuals,should take to protect the individuals from potential harm, including
Contractor's provision of notifications, credit protection, claims monitoring, and any specific
protections for a Legally Authorized Representative to take on behalf of an individual with special
capacity or circumstances;
i.The steps Contractor has taken to mitigate the harm or potential harm caused(including without
limitation the provision of sufficient resources to mitigate);
j.The steps Contractor has taken,or will take,to prevent or reduce the likelihood of recurrence of
a similar Breach:
k.Identify,describe or estimate of the persons,Workforce Subcontractoror individuals and any
law enforcement that may be involved in the Breach:
1.A reasonable schedule for Contractor to provide regular updates regarding response to the B eac
but no less than every three(3)business days,or as otherwise directed by HHS in writing,including
information about risk estimations,reporting,notification,if any,mitigation,corrective action,root
cause analysis and when such activities are expected to be completed;and
m.Any reasonably available,pertinent information,documents or reports related to a Breach that
HHS requests following Discovery.
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Section 4.04. Investigation.Response and Mitigation.
(A) Contractor shall immediately conduct a full and complete investigation,respond to the
Breach,commit necessary and appropriate staff and resources to expeditiously respond,and report
as required to HHS for incident response purposes and for purposes of HHS's compliance with
report and notification requirements,to the satisfaction of HHS.
(B) Contractor shall complete or participate in a risk assessment as directed by HHS following
a Breach,and provide the final assessment,corrective actions and mitigations to HHS for review
and approval.
(C) Contractor shall fully cooperate with HHS to respond to inquiries and/or proceedings by
state and federal authorities,persons and/or individuals about the Breach.
(D) Contractor shall fully cooperate with HHS's efforts to seek appropriate injunctive relief or
otherwise prevent or curtail such Breac or to recover or protect any Confidential Information
including complying with reasonable corrective action or measures, as specified by HHS in a
Corrective Action Plan if directed by HHS under the Base Contract.
Section 4.05. Breach Notification to Individuals and Reportine to Authorities.
(A) HHS may direct Contractor to provide Breach notification to individuals,regulators or
third-parties,as specified by HHS following a Breach.
(B) Contractor must comply with all applicable legal and regulatory requirements in the time,
manner and content of any notification to individuals,regulators or third-parties,or any notice
required by other state or federal authorities. Notice letters will be in Contractor's name and on
Contractor's letterhead,unless otherwise directed by HHS,and will contain contact information,
including the name and title of Contractor's representative, an email address and a toll-free
telephone number,for the individual to obtain additional information.
(C) Contractor shall provide HHS with draft notifications for HHS approval prior to
distribution and copies of distributed and approved communications.
(D) Contractor shall have the burden of demonstrating to the satisfaction of HHS that any
required notification was timely made. If there are delays outside of Contractors control,
Contractor shall provide written documentation to HHS of the reasons for the delay.
(E) If HHS directs Contractor to provide notifications, HHS shall, in the time and manner
reasonably requested by Contractor,cooperate and assist with Contractor's information requests in
order to make such notifications.
ARTICLE 5. GENERAL PROVISIONS
Section 5.01 Ownership of Confidential Information
Contractor acknowledges and agrees that the Confidential Information is and shall remain the property of HHS.
Contractor agrees it acquires no title or rights to the Confidential Information.
Section 5.02 HHS Commitment and Obligations
HHS will not request Contractor to create,maintain,transmit,use or disclose PHI in any manner that would
not be permissible under applicable law if done by HHS.
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Section 5.03 HHS Right to Inspection
At any time upon reasonable notice to Contractor,or if HHS determines that Contractor has violated this DUA,
HHS,directly or through its agent,will have the right to inspect the facilities,systems,books and records of
Contractor to monitor compliance with this DUA. For purposes of this subsection,HHS's agent(s)include,
without limitation,the HHS Office of the Inspector General,the Office of the Attorney General of Texas,the
State Auditor's Office,outside consultants,legal counsel or other designee.
Section 5.04 Term,Termination of DUA:Survival
This DUA will be effective on the date on which Contractor executes the Base Contract,and will terminate
upon termination of the Base Contract and as set forth herein. If the Base Contract is extended,this DUA is
extended to run concurrent with the Base Contract
(A) If HHS determines that Contractor has violated a material term of this DUA;HHS may in
its sole discretion:
(1) Exercise any of its rights including but not limited to reports,access and inspection under
this DUA and/or the Base Contract;or
(2) Require Contractor to submit to a corrective action plan,including a plan for monitoring
and plan for reporting as HHS may determine necessary to maintain compliance with this DUA;or
(3) Provide Contractor with a reasonable period to cure the violation as determined by HHS;
or
(4) Terminate the DUA and Base Contract immediately,and seek relief in a court of competent
jurisdiction in Travis County,Texas.
Before exercising any of these options, HHS will provide written notice to Contractor describing the
violation and the action it intends to take.
(B) If neither termination nor cure is feasible,HHS shall report the violation to the applicable
regulatory authorities.
(C) The duties of Contractor or its Subcontractor under this DUA survive the expiration or
termination of this DUA until all the Confidential Information is Destroyed or returned to HHS,as required
by this DUA.
Section 5.05 Injunctive Relief
(A) Contractor acknowledges and agrees that HHS may suffer irreparable injury if Contractor
or its Subcontractor fails to comply with any of the terms of this DUA with respect to the Confidential
Information or a provision of or other laws or regulations applicable to Confidential Information.
(B) Contractor further agrees that monetary damages may be inadequate to compensate HHS
for Contractor's or its Subcontractor's failure to comply. Accordingly,Contractor agrees that HHS will,in
addition to any other remedies available to it at law or in equity,be entitled to seek injunctive relief without
posting a bond and without the necessity of demonstrating actual damages,to enforce the terms of this
DUA.
Section 5.06 Indemnification
Contractor shall indemnify,defend and hold harmless HHS and its respective Executive Commissioner,
employees,Subcontractors.agents(including other state agencies acting on behalf of HHS)or other members
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..._..........
.
of HHS'Workforce(each of the foregoing hereinafter referred to as"Indemnified Party')against all actual and
direct losses suffered by the Indemnified Party and all liability to third parties arising from or in connection
with any breach of this DUA or from any acts or omissions related to this DUA by Contractor or its employees,
directors, officers, Subcontractors, or agents or other members of Contractor's Workforce. The duty to
indemnify,defend and hold harmless is independent of the duty to insure. Upon demand,Contractor shall
reimburse HHS for any and all losses,liabilities,lost profits,fines,penalties,costs or expenses(including costs
of required notices,investigation,and mitigation of a Breach.fines or penalties imposed on an Indemnified
Party by a regulatory authority,and reasonable attorneys'fees)which may be imposed upon any Indemnified
Party to the extent caused by and which results from the Contractor's failure to meet any of its obligations
under this DUA. Contractor's obligation to defend,indemnify and hold harmless any Indemnified Party will
survive the expiration or termination of this DUA
Section 5.07 Insurance
(A) In addition to any insurance required in the Base Contract,at HHS's option,HHS may
require Contractor to maintain, at its expense,the special and/or custom first-and third-party insurance
coverages,including without limitation data breach,cyber liability,crime theft and notification expense
coverages,with policy limits sufficient to cover any liability arising under this DUA,naming the State of
Texas, acting through HHS, as an additional named insured and loss payee, with primary and non-
contributory status.
(B) Contractor shall provide HHS with written proof that required insurance coverage is in
effect,at the request of HHS.
Section 5.08 Entirety of the Contract
This DUA is incorporated by reference into the Base Contract and,together with the Base Contract,constitutes
the entire agreement between the parties. No change,waiver,or discharge of obligations arising under those
documents will be valid unless in writing and executed by the party against whom such change,waiver,or
discharge is sought to be enforced.
Section 5.09 Automatic Amendment and Interpretation
Upon the effective date of any amendment or issuance of additional regulations to any law applicable to
Confidential hdomratioa this DUA will automatically be amended so that the obligations imposed on HHS
and/or Contractor remain in compliance with such requirements. Any ambiguity in this DUA will be resolved
in favor of a meaning that permits HHS and Contractor to comply with laws applicable to Confidential
Information.
Section 510 Notices,Requests for Approval
All notices and requests for approval related to this DUA must be directed to the HHS Chief Privacy Officer at
privic-y^hhsc.s tate.tx.us.
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I S Contract"dr
ATTACHMENT 1. SUBCONTRACTOR AGREEMENT FORM
HHS CONTRACT NUMBER
The DUA between HHS and Contractor establishes the permitted and required uses and disclosures of
Confidential Information by Contractor.
Contractor has subcontracted with (Subcontractor)for
performance of duties on behalf of CONTRACTOR which are subject to the DUA Subcontractor
acknowledges,understands and agrees to be bound by the same terms and conditions applicable to
Contractor under the DUA,incorporated by reference in this Agreement,with respect to HHS
Confidential Information.Contractor and Subcontractor agree that HHS is a third-party beneficiary to
applicable provisions of the subcontract.
HHS has the right,but not the obligation,to review or approve the terms and conditions of the
subcontract by virtue of this Subcontractor Agreement Form.
Contractor and Subcontractor assure HHS that any Breach as defined by the DUA that Subcontractor
Discovers shall be reported to HHS by Contractor in the time,manner and content required by the DUA
If Contractor knows or should have known in the exercise of reasonable diligence of a pattern of activity
or practice by Subcontractor that constitutes a material breach or violation of the DUA or the
Subcontractor's obligations,Contractor shall:
1. Take reasonable steps to cure the violation or end the violation,as applicable;
2. If the steps are unsuccessful,terminate the contract or arrangement with Subcontractor,if
feasible;
3. Notify HHS immediately upon DisQoveLXof the pattern of activity or practice of Subcontractor
that constitutes a material breach or violation of the DUA and keep HHS reasonably and
regularly informed about steps Contractor is taking to cure or end the violation or terminate
Subcontractor's contract or arrangement.
This Subcontractor Agreement Form is executed by the parties in their capacities indicated below.
CONTRACTOR SUBCONTRACTOR
BY: BY:
NAME: NAME:
TfrLE: TITLE:
DATE ,201 . DATE:
HHS Data Use Agreement v.8.4 November 12,2017
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ATTACHMENT H
GENERAL AFFIRMATIONS
By entering into this Contract,Grantee affirms,without exception, as follows:
A. Contractor represents and warrants that these Contract Affirmations apply to Contractor
and all of Contractor's principals,officers,directors, shareholders,partners, owners,
agents, employees, subcontractors, independent contractors,and any other representatives
who may provide services under, who have a financial interest in, or otherwise are
interested in this Contract and any related Solicitation.
B. Contractor represents and warrants that all statements and information provided to HHSC
are current, complete, and accurate. This includes all statements and information in this
Contract and any related Solicitation Response.
C. Contractor understands that HHSC will comply with the Texas Public Information Act
(Chapter 552 of the Texas Government Code)as interpreted by judicial rulings and
opinions of the Attorney General of the State of Texas. Information,documentation, and
other material prepared and submitted in connection with this Contract or any related
Solicitation may be subject to public disclosure pursuant to the Texas Public Information
Act. In accordance with Section 2252.907 of the Texas Government Code,Contractor is
required to make any information created or exchanged with the State pursuant to the
Contract, and not otherwise excepted from disclosure under the Texas Public Information
Act, available in a format that is accessible by the public at no additional charge to the
State.
D. Contractor accepts the Solicitation terms and conditions unless specifically noted by
exceptions advanced in the form and manner directed in the Solicitation, if any, under
which this Contract was awarded. Contractor agrees that all exceptions to the Solicitation,
if any, are rejected unless expressly accepted by HHSC in writing.
E. Contractor agrees that HHSC has the right to use,produce, and distribute copies of and to
disclose to HHSC employees, agents, and contractors and other governmental entities all
or part of this Contract or any related Solicitation Response as HHSC deems necessary to
complete the procurement process or comply with state or federal laws.
F. Contractor generally releases from liability and waives all claims against any party
providing information about the Contractor at the request of HHSC.
G. Contractor has not given,has not offered to give, and does not intend to give at any time
hereafter any economic opportunity, future employment, gift, loan, gratuity, special
discount,trip, favor,or service to a public servant in connection with this Contract or any
related Solicitation,or related Solicitation Response.
H. Under Section 2155.004,Texas Government Code(relating to financial participation in
preparing solicitations), Contractor certifies that the individual or business entity named
in this Contract and any related Solicitation Response is not ineligible to receive this
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Contract and acknowledges that this Contract may be terminated and payment withheld if
this certification is inaccurate.
I. Under Sections 2155.006 and 2261.053 of the Texas Government Code(relating to
convictions and penalties regarding Hurricane Rita, Hurricane Katrina, and other
disasters),the Contractor certifies that the individual or business entity named in this
Contract and any related Solicitation Response is not ineligible to receive this Contract
and acknowledges that this Contract may be terminated and payment withheld if this
certification is inaccurate.
J. Under Section 231.006(d)of the Texas Family Code regarding child support, Contractor
certifies that the individual or business entity named in this Contract and any related
Solicitation Response is not ineligible to receive the specified payment and acknowledges
that the Contract may be terminated and payment may be withheld if this certification is
inaccurate.
K. Contractor certifies that it and its principals are not suspended or debarred from doing
business with the state or federal government as listed on the State of Texas Debarred
Vendor List maintained by the Texas Comptroller of Public Accounts and the System for
Award Management(SAM)maintained by the General Services Administration. This
certification is made pursuant to the regulations implementing Executive Order 12549
and Executive Order 12689,Debarment and Suspension, 2 C.F.R. Part 376, and any
relevant regulations promulgated by the Department or Agency funding this project. This
provision shall be included in its entirety in Contractor's subcontracts, if any, if payment
in whole or in part is from federal funds.
L. Contractor certifies that it is not listed on the federal government's terrorism watch list as
described in Executive Order 13224.
M. Contractor represents and warrants that it is not engaged in business with Iran, Sudan,or
a foreign terrorist organization, as prohibited by Section 2252.152 of the Texas
Government Code.
N. In accordance with Section 669.003 of the Texas Government Code, relating to
contracting with the executive head of a state agency, Contractor certifies that it is not(1)
the executive head of an HHS agency, (2)a person who at any time during the four years
before the date of this Contract was the executive head of an HHS agency, or(3) a person
who employs a current or former executive head of an HHS agency.
O. Contractor represents and warrants that it is not currently delinquent in the payment of
any franchise taxes owed the State of Texas under Chapter 171 of the Texas Tax Code.
P. Contractor agrees that any payments due under this Contract shall be applied towards any
debt or delinquency that is owed to the State of Texas.
Q. Contractor represents and warrants that payments to Contractor and Contractor's receipt
of appropriated or other funds under this Contract or any related Solicitation are not
prohibited by Sections 556.005, 556.0055, or 556.008 of the Texas Government Code
(relating to use of appropriated money or state funds to employ or pay lobbyists, lobbying
expenses, or influence legislation).
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R. Contractor agrees to comply with Section 2155.4441 of the Texas Government Code,
requiring the purchase of products and materials produced in the State of Texas in
performing service contracts.
S. Contractor agrees that upon request of HHSC, Contractor shall provide copies of its most
recent business continuity and disaster recovery plans.
T. Contractor expressly acknowledges that state funds may not be expended in connection
with the purchase of an automated information system unless that system meets certain
statutory requirements relating to accessibility by persons with visual impairments.
Accordingly, Contractor represents and warrants to HHSC that the technology provided
to HHSC for purchase(if applicable under this Contract or any related Solicitation) is
capable, either by virtue of features included within the technology or because it is
readily adaptable by use with other technology,of.
•providing equivalent access for effective use by both visual and non-visual means;
• presenting information, including prompts used for interactive communications,
in formats intended for non-visual use; and
• being integrated into networks for obtaining, retrieving, and disseminating
information used by individuals who are not blind or visually impaired.
For purposes of this Section, the phrase "equivalent access" means a substantially similar
ability to communicate with or make use of the technology, either directly by features
incorporated within the technology or by other reasonable means such as assistive devices
or services which would constitute reasonable accommodations under the Americans With
Disabilities Act or similar state or federal laws. Examples of methods by which equivalent
access may be provided include, but are not limited to, keyboard alternatives to mouse
commands and other means of navigating graphical displays, and customizable display
appearance.
In accordance with Section 2157.005 of the Texas Government Code, the Technology
Access Clause contract provision remains in effect for any contract entered into before
September 1, 2006.
U. If this Contract is for the purchase or lease of computer equipment,then Contractor
certifies that it is in compliance with Subchapter Y, Chapter 361 of the Texas Health and
Safety Code related to the Computer Equipment Recycling Program and the Texas
Commission on Environmental Quality rules in 30 TAC Chapter 328.
V. If this Contract is for the purchase or lease of covered television equipment, then
Contractor certifies that it is compliance with Subchapter Z,Chapter 361 of the Texas
Health and Safety Code related to the Television Equipment Recycling Program.
W. Contractor represents and warrants,during the twelve(12)month period immediately
prior to the date of the execution of this Contract,none of its employees including,but
not limited to those will provide services under the Contract,was an employee of an HHS
Agency. Pursuant to Section 2252.901,Texas Government Code(relating to prohibitions
regarding contracts with and involving former and retired state agency employees),
Contractor will not allow any former employee of the System Agency to perform services
under this Contract during the twelve(12)month period immediately following the
employee's last date of employment at the System Agency.
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X. Contractor acknowledges that,pursuant to Section 572.069 of the Texas Government
Code, a former state officer or employee of a state agency who during the period of state
service or employment participated on behalf of a state agency in a procurement or
contract negotiation involving Contractor may not accept employment from Contractor
before the second anniversary of the date the Contract is signed or the procurement is
terminated or withdrawn.
Y. If this Contract is for consulting services under Chapter 2254 of the Texas Government
Code, in accordance with Section 2254.033 of the Texas Government Code,Contractor
certifies that it does not employ an individual who was employed by System Agency or
another agency at any time during the two years preceding the submission of any related
Solicitation Response related to this Contract or, in the alternative, Contractor has
disclosed in any related Solicitation Response the following: (i)the nature of the previous
employment with System Agency or the other agency; (ii)the date the employment was
terminated; and(iii)the annual rate of compensation at the time of the employment was
terminated.
Z. Contractor represents and warrants that it has no actual or potential conflicts of interest in
providing the requested goods or services to HHSC under this Contract or any related
Solicitation and that Contractor's provision of the requested goods and/or services under
this Contract and any related Solicitation will not constitute an actual or potential conflict
of interest or reasonably create an appearance of impropriety.
AA. Contractor understands that HHSC does not tolerate any type of fraud. The agency's
policy is to promote consistent, legal, and ethical organizational behavior by assigning
responsibilities and providing guidelines to enforce controls. Violations of law, agency
policies,or standards of ethical conduct will be investigated, and appropriate actions will
be taken. All employees or contractors who suspect fraud,waste or abuse(including
employee misconduct that would constitute fraud, waste, or abuse) are required to
immediately report the questionable activity to both the Health and Human Services
Commission's Office of the Inspector General at 1-800-436-6184 and the State Auditor's
Office. Contractor agrees to comply with all applicable laws,rules,regulations, and
HHSC policies regarding fraud including,but not limited to, HHS Circular C-027.
BB. The undersigned affirms under penalty of perjury of the laws of the State of Texas that
(a) in connection with this Contract and any related Solicitation Response,neither I nor
any representative of the Contractor has violated any provision of the Texas Free
Enterprise and Antitrust Act,Tex. Bus. &Comm. Code Chapter 15; (b) in connection
with this Contract and any related Solicitation Response,neither I nor any representative
of the Contractor has violated any federal antitrust law; and(c)neither I nor any
representative of the Contractor has directly or indirectly communicated any of the
contents of this Contract and any related Solicitation Response to a competitor of the
Contractor or any other company, corporation, firm,partnership or individual engaged in
the same line of business as the Contractor.
CC. Contractor represents and warrants that it is not aware of and has received no notice of
any court or governmental agency proceeding, investigation, or other action pending or
threatened against Contractor or any of the individuals or entities included in numbered
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paragraph 1 of these Contract Affirmations within the five(5)calendar years immediately
preceding execution of this Contract or the submission of any related Solicitation
Response that would or could impair Contractor's performance under this Contract,relate
to the contracted or similar goods or services,or otherwise be relevant to HHSC's
consideration of entering into this Contract. If Contractor is unable to make the preceding
representation and warranty,then Contractor instead represents and warrants that it has
provided to HHSC a complete,detailed disclosure of any such court or governmental
agency proceeding, investigation, or other action that would or could impair Contractor's
performance under this Contract,relate to the contracted or similar goods or services, or
otherwise be relevant to HHSC's consideration of entering into this Contract. In addition,
Contractor acknowledges this is a continuing disclosure requirement. Contractor
represents and warrants that Contractor shall notify HHSC in writing within five(5)
business days of any changes to the representations or warranties in this clause and
understands that failure to so timely update HHSC shall constitute breach of contract and
may result in immediate contract termination.
DD. Contractor represents and warrants that, pursuant to Section 2270.002 of the Texas
Government Code, Contractor does not boycott Israel and will not boycott Israel during
the term of this Contract.
EE. Contractor certifies that for contracts for services, Contractor shall utilize the U.S.
Department of Homeland Security's E-Verify system during the term of this Contract to
determine the eligibility of:
(a) all persons employed by Contractor to perform duties within Texas; and
(b) all persons, including subcontractors, assigned by Contractor to perform work
pursuant to this Contract within the United States of America.
FF. Contractor understands, acknowledges, and agrees that any false representation or any
failure to comply with a representation,warranty, or certification made by Contractor is
subject to all civil and criminal consequences provided at law or in equity including,but
not limited to, immediate termination of this Contract.
GG. Contractor represents and warrants that it will comply with all applicable laws and
maintain all permits and licenses required by applicable city,county, state, and federal
rules,regulations, statutes, codes, and other laws that pertain to this Contract.
HH. Contractor represents and warrants that all statements and information prepared and
submitted by Contractor in this Contract and any related Solicitation Response are
current, complete,true, and accurate. Contractor acknowledges any false statement or
material misrepresentation made by Contractor during the performance of this Contract
or any related Solicitation is a material breach of contract and may void this Contract.
Further, Contractor understands, acknowledges, and agrees that any false representation
or any failure to comply with a representation,warranty, or certification made by
Contractor is subject to all civil and criminal consequences provided at law or in equity
including,but not limited to, immediate termination of this Contract.
II. Contractor represents and warrants that the individual signing this Contract is authorized
to sign on behalf of Contractor and to bind the Contractor.
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Authorized representative on behalf of Contractor must complete and sign the following:
Legal Name of Contractor:
Signature of Authorized Date Signed
Representative
Printed Name and Title of Phone Number
Authorized Representative
Federal Employer Identification Fax Number
Number
DUNS Number Email Address
Physical Street Address City, State,Zip Code
Mailing Address,if different City, State, Zip Code
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ATTACHMENT I
NON-EXCLUSIVE LIST OF APPLICABLE LAWS
Contractor is responsible for reviewing and complying with any applicable statutes, rules,
regulations, executive orders and policies.To the extent applicable to Grantee, Grantee shall
comply with the following:
1. Statutes,rules,regulations, and HHSC policy(and any of their subsequent amendments)that
collectively prohibit discrimination, exclusion from or limitation of participation in programs,
benefits or activities or denial of any aid,care, service or other benefit on the basis of race,color,
national origin, limited English proficiency, sex, sexual orientation(where applicable),
disabilities, age, substance abuse,political belief or religion:
a. Title VI of the Civil Rights Act of 1964,42 USC §§ 2000d et seq.;
b. Title IX of the Education Amendments of 1972,20 USC §§ 1681-1683, and 1685-1686;
c. Section 504 of the Rehabilitation Act of 1973,29 USC § 794(a);
d. Americans with Disabilities Act of 1990,42 USC §§ 12101 et seq.;
e. Age Discrimination Act of 1975,42 USC §§ 6101-6107;
f. Comprehensive Alcohol Abuse and Alcoholism Prevention,Treatment and Rehabilitation
Act of 1970,42 USC § 290dd(b)(1); 7)45 CFR Parts 80, 84, 86 and 91;
g. U.S. Department of Labor,Equal Employment Opportunity E.O. 11246;
h. Tex. Labor Code Chapter 21;
i. Food Stamp Act of 1977 (7 USC §§ 2011 et seq.);
j. Executive Order 13279, 45 CFR Part 87 or 7 CFR Part 16 regarding equal treatment and
opportunity for religious organizations;
k. Drug Abuse Office and Treatment Act of 1972, 21 USC §§ 1101 et seq.,relating to drug
abuse;
1. Public Health Service Act of 1912, §§ 523 and 527,42 USC § 290dd-2,and 42 CFR pt.
2,relating to confidentiality of alcohol and drug abuse patient records;
m. Title VIII of the Civil Rights Act of 1968,42 USC §§ 3601 et seq., relating to
a. nondiscrimination in housing; and
n. Non-discrimination Policy for HHSC Programs;
2. Immigration Reform and Control Act of 1986, 8 USC § 1324a, and Immigration Act of 1990,
8 USC 1101 et seq., as amended by Public Lawl 13-4(March 7, 2013),regarding employment
verification; and Illegal Immigration Reform and Immigrant Responsibility Act of 1996;
3. Pro-Children Act of 1994,20 USC §§ 6081-6084, and the Pro-Children Act of 2001, 20 USC
§7183,regarding the non-use of all tobacco products;
4.National Research Service Award Act of 1971, 42 USC §§ 289a-1 et seq., and 6601 (P.L. 93-
348 and P.L. 103-43),regarding human subjects involved in research;
5. Hatch Political Activity Act, 5 USC §§ 1501-1508 and 7324-26,which limits the political
activity of employees whose employment is funded with federal funds;
f. Fair Labor Standards Act,29 USC §§ 201 et seq., and the Intergovernmental Personnel Act of
1970,42 USC §§ 4701 et seq., as applicable,concerning minimum wage and maximum hours;
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6. Texas Government Code Chapter 469 pertaining to eliminating architectural barriers for
persons with disabilities;
7. Texas Workers' Compensation Act, Texas Labor Code Chapters 401-406, and 28 Texas
Administrative Code(TAC)pt. 2,regarding compensation for employees' injuries;
8. The Clinical Laboratory Improvement Amendments of 1988,42 USC § 263a,regarding the
regulation and certification of clinical laboratories;
j.The Occupational Safety and Health Administration Regulations on Blood Borne Pathogens,
29 CFR§ 1910.1030, or Title 25 Tex.Admin Code Chapter 96 regarding safety standards for
handling blood borne pathogens;
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9. Laboratory Animal Welfare Act of 1966, 7 USC §§ 2131 et seq.,pertaining to the treatment of
laboratory animals;
10. Environmental standards pursuant to the following:
a. Institution of environmental quality control measures under the National
Environmental Policy Act of 1969,42 USC §§ 4321-4347 and Executive Order
11514(35 Fed. Reg.4247), "Protection and Enhancement of Environmental Quality;"
b. Notification of violating facilities pursuant to Executive Order 11738 (40 CFR Part
32),"Providing for Administration of the Clean Air Act and the Federal Water
Pollution Control Act with respect to Federal Contracts, Grants, or Loans;"
c. Protection of wetlands pursuant to Executive Order 11990,42 Fed. Reg. 26961;
d. Evaluation of flood hazards in floodplains in accordance with Executive Order 11988,
42 Fed. Reg. 26951 and, if applicable, flood insurance purchase requirements of
Section 102(a)of the Flood Disaster Protection Act of 1973 (P.L. 93-234);
e. Assurance of project consistency with the approved State Management program
developed under the Coastal Zone Management Act of 1972, 16 USC §§ 1451 et seq.;
f. Federal Water Pollution Control Act, 33 USC §§ 1251 et seq.;
g. Protection of underground sources of drinking water under the Safe Drinking Water
Act of 1974,42 USC §§ 300f-300j;
h. Protection of endangered species under the Endangered Species Act of 1973, 16 USC
§§ 1531 et seq.;
i. Conformity of federal actions to state clean air implementation plans under the Clean
Air Act of 1955,42 USC §§ 7401 et seq.;
j. Wild and Scenic Rivers Act of 1968, 16 USC §§ 1271 et seq.,related to protecting
certain river systems; and
11. Lead-Based Paint Poisoning Prevention Act,42 USC §§ 4821 et seq.,prohibiting the use of
lead-based paint in residential construction or rehabilitation;
12. Intergovernmental Personnel Act of 1970,42 USC §§ 4278-4763,regarding personnel merit
systems for programs specified in Appendix A of the federal Office of Program Management's
Standards for a Merit System of Personnel Administration, 5 CFR Part1200 et seq;
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13.Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies
Act of,42 USC §§4601 et seq(PL 91-646),relating to fair treatment of persons displaced or
whose property is acquired as a result of Federal or federally-assisted programs;
14. Davis-Bacon Act,40 USC §§ 3141-3148;
15. Copeland Act,40 USC §§ 276c and 18 USC § 874;
16. Contract Work Hours and Safety Standards Act, 40 USC § 3702 et seq.,regarding labor
standards for federally-assisted construction subagreements;
17.National Historic Preservation Act of 1966, § 106, 16 USC § 470;Executive Order 11593;
and the Archaeological and Historic Preservation Act of 1974(16 USC §§ 469a-1 et seq.)
regarding historic property to the extent necessary to assist HHSC in complying with the Acts;
18. Trafficking Victims Protection Act of 2000, Section 106(g)(22 USC § 7104);
19. Executive Order 13513 (Oct. 1,2009), Federal Leadership on Reducing Text Messaging
While Driving, October 1, 2009, if required by a federal funding source of this Contract;
20. Whistleblower Protection Enhancement Act(5 U.S.C. 2302(b)(8)) and Texas Whistleblower
Act(Tex. Gov. Code Chapter 554); and
21. Requirements of any other applicable state and federal statutes, executive orders, regulations,
rules and policies.
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Fiscal Federal Funding Accountability and Transparency Act
(FFATA)CERTIFICATION
The certifications enumerated below represent material facts upon which DSHS relies when reporting
information to the federal government required under federal law. If the Department later determines
that the Contractor knowingly rendered an erroneous certification, DSHS may pursue all available
remedies in accordance with Texas and U.S. law. Signor further agrees that it will provide immediate
written notice to DSHS if at any time Signor learns that any of the certifications provided for below were
erroneous when submitted or have since become erroneous by reason of changed circumstances. If the
Signor cannot certify all of the statements contained in this section Signor must provide written
notice to DSHS detailing which of the below statements it cannot certify and why.
Legal Name of Contractor: FFATA Contact#1 Name,Email and Phone Number:
Primary Address of Contractor: FFATA Contact#2 Name,Email and Phone Number:
ZIP Code:9-digits Required www.usps.com DUNS Number:9-digits Required www.sam.gov
State of Texas Comptroller Vendor Identification Number(VIN)14 Digits
Printed Name of Authorized Representative Signature of Authorized Representative
Robert Isbell
Title of Authorized Representative Date
-1-
Department of State Health SenAces Form 4734—June 2013
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Fiscal Federal Funding Accountability and Transparency Act
(FFATA) CERTIFICATION
As the duly authorized representative(Signor)of the Contractor,I hereby certify that
the statements made by me in this certification form are true,complete and correct to
the best of my knowledge.
Did your organization have a gross income, from all sources, of less than $300,000 in
your previous tax year?❑Yes ❑ No
If your answer is"Yes",skip questions"A","B",and"C"and finish the certification.
If your answer is"No",answer questions "A"and"B".
A.Certification Regarding%of Annual Gross from Federal Awards.
Did your organization receive 80% or more of its annual gross revenue from federal
awards during the preceding fiscal year?❑Yes ❑ No
B.Certification Regarding Amount of Annual Gross from Federal Awards.
Did your organization receive$25 million or more in annual gross revenues from federal
awards in the preceding fiscal year?❑Yes ❑ No
If your answer is"Yes"to both question "A"and"B",you must answer question"C".
If your answer is "No" to either question "A" or "B", skip question "C" and finish the
certification.
C.Certification Regarding Public Access to Compensation Information.
Does the public have access to information about the compensation of the senior
executives in your business or organization (including parent organization, all branches,
and all affiliates worldwide)through periodic reports filed under section 13(a) or 15(d)
of the Securities Exchange Act of 1934(15 U.S.C. 78m(a), 78o(d))or section 6104 of the
Internal Revenue Code of 1986?❑Yes ❑ No
If your answer is"Yes"to this question,where can this information be accessed?
If your answer is "No" to this question, you must provide the names and total
compensation of the top five highly compensated officers below.
Provide compensation information here:
-2-
Department of State Health Services Form 4734—June 2013
System Agency Contract No.HHS000508300001 Page 64 of 64
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Certificate Of Completion
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