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Health Board Interagency Agreement i5~~@UE ~Ýk-~ MEMORANDUM June 25, 2004 TO: The Honorable Mayor and City Council Members FROM: Michael C. Van Milligen, City Manager SUBJECT: Interagency Agreement between the City of Dubuque and the Dubuque County Board of Health for Inspection of Pools and Spas in Dubuque County Public Health Specialist Mary Rose Corrigan recommends City Council approval of an Interagency Agreement with the Dubuque County Board of Health for inspection and enforcement of swimming pools and spas in Dubuque County. I concur with the recommendation and respectfully request Mayor and City Council approval. M ¡jft f:fi~ MCVM/jh Attachment cc: Barry Lindahl, Corporation Counsel Cindy Steinhauser, Assistant City Manager Mary Rose Corrigan, RN, Public Health Specialist , "0 ! , "j .. '.' ~") i5~~@UE ~Ýk-~ MEMORANDUM June 21,2004 FROM: Michael C. Van Milligen~anager Mary Rose COrrigan~ Public Health Specialist TO: SUBJECT: Interagency Agreement between the City of Dubuque and the Dubuque County Board of Health for Inspection of Pools and Spas in Dubuque County INTRODUCTION This memorandum provides a recommendation for updating the City's contract for the inspection of swimming pools and spas. BACKGROUND Since 1991, the City of Dubuque Health Services Department has maintained an interagency agreement with the Iowa Department of Public Health to enforce the State swimming pool and spa inspection program consistent with the provisions of Chapter 641-15, lAC. We have maintained this agreement by performing the necessary duties to uphold it and by participating in annual audits by the Iowa Department of Public Health swimming pool/spa staff. The City inspects public pools and spas within the city limits, and also in the county. We currently have two certified pool operators on staff who have also undergone specific training required for inspectors by the Iowa Department of Public Health. DISCUSSION The existing contract is between the Iowa Department of Public Health and the Dubuque County Board of Health. Swimming pool/spa agreements must go through local boards of health. Attached is the contract between the Iowa Department of Public Health and the Dubuque County Board of Health. Also attached, is an interagency agreement between the Dubuque County Board of Health and the City of Dubuque. This interagency agreement basically details the duties of the inspecting agency and passes on the responsibility of the Board's contract with the Iowa Department of Public Health to the City of Dubuque Health Services Department. We do not anticipate any change in service. As always, if an enforcement proceeding involving the courts would be necessary in the county, we would work with the County Attorney. To date, we have not had to resort to these matters. Pool and spa owners have been compliant in correcting deficiencies since the rules and regulations provide for an effective means of enforcement without court action. RECOMMENDATION It is recommended that the City Council approve the attached Interagency Agreement with the Dubuque County Board of Health for the inspection and enforcement of swimming pools and spas. CITY COUNCIL ACTION The City Council authorize the City Manager to sign the agreement with the Dubuque County Board of Health for inspection of swimming pools and spas in Dubuque County. MRC/cj cc: Paul Buss, Director, Dubuque County Health Department INTERAGENCY AGREEMENT BETWEEN THE DUBUQUE COUNTY BOARD OF HEALTH AND THE CITY OF DUBUQUE This Agreement is made and entered into between the Dubuque County Board of Health (hereinafter referred to as Board) and the City of Dubuque (hereinafter referred to as City). 1. Authority. This agreement is entered into pursuant to the provisions of Iowa Code Chapter 28E and shall constitute the entire agreement between the Board and the City with respect to the inspection and enforcement of swimming pools and spas. Nothing in this agreement or its attachments shall be construed as limiting the power of the Board to inspect, enforce or to take any other actions necessary for the continued proper administration of rules and regulations relating to the swimming pool and spa program. If any provision contained herein is in conflict with any State, Federal or Local law or shall be declared to be invalid by any court of record of this State, such invalidity shall affect only such portions as are declared invalid or in conflict with the law. 2. Statement of Purpose: The purpose of this Agreement is to delegate the Board's inspection and enforcement authority with respect to swimming pool and spa operation, as specified in 1989 Iowa Code Supplement Chapter 1351 and Chapters 641-15, lAC, and in the 28E Agreement with the Iowa Department of Public Health, and to specify the extent and manner of cooperation between the two agencies in conducting programs for the inspection and enforcement of rules relating to swimming pools and spas. 3. Duties. The duties of the parties are listed in Attachments A and B, which are hereby made a part of this agreement. 4. Period of Aareement. This agreement is valid from July 1, 2004 and shall continue until June 30, 2005. 5. Leqal or Administrative Entity Created: No new legal or administrative entity is created by this agreement. 6. Manner of Financinq: The functions to be performed by the City under the provisions of this agreement, are to be financed by the City. The City shall collect registration fees pursuant to the Iowa Code 1351 and 641-Chapter 15, Iowa Administrative Code. 7. Reportina. The City shall provide the Board and the Iowa Department of Public Health with a report of its inspection and enforcement activity on an annual basis. These reports are due at the Iowa Department of Public Health no later than: (I) Annual Report (July 1 - June 30) submitted not later than August 1 that shall include the following: 1. Monthly breakdown of the number of inspections, for each type of inspection. 2. Number of enforcement actions required to eliminate deficiencies, for each type of inspection. 3. Number of facilities closed, for each type of facility. (II) January 10 for the 4th calendar quarter, for the period 1 July thru December 31. These semi-annual reports shall consist of: (I) The number of inspections conducted during the period. (II) Number of pools/spas requiring enforcement action. (III) Number of pools/spas closed. (IV) Number of pools/spas where legal action was required to eliminate deficiencies. 8. Termination: The Board or the City may terminate this agreement by providing to the other party a written notice of intent to terminate this agreement, at least 30 days prior to the intended date of termination. The notice shall specify the reasons for termination, and shall be delivered via U.S. certified mail. Upon termination, the City shall transfer to the Board all inspection and enforcement records in its possession and all other documents generated as a result of this program not later than 30 days following the stated termination date. IN WITNESS WHEREOF, the Board and the City have executed two copies of this Agreement, each shall be considered an original. CITY OF DUBUQUE Michael C. Van Milligen City Manager Date ATTACHMENT A DUTIES OF CITY OF DUBUQUE 1. Personnel. The City states that it has or will acquire all personnel required for the performance of the work specified. The City shall continue to employ sufficient personnel to perform the services of this contract. 2. Compliance. Inspections and Monitorinq: The City has the primary responsibility for enforcing the rules relating to the inspection and enforcement of the swimming pool and spa programs (Chapters 15, lAC). Nothing in this agreement however, shall constitute (or be construed to constitute) a valid defense by regulated parties in violation of any local, state or federal statute, regulation or permit. The City may provide public information and consultation to the public and swimming pool and spa operators in addition to inspection services to eliminate or minimize potential health and safety problems. 3. Violations. Violation of the provisions of Chapters 15, Iowa Administrative Code and City of Dubuque Ordinance or Board Rules shall be addressed through the penalty for noncompliance provisions of the City of Dubuque ordinance or of any other applicable ordinance, resolution, rules and/or regulations. 4. Interqovernmental Cooperation: The City shall submit such information as the Board may require to show compliance with the swimming pool and spa program rules and the adequate implementation of the inspection and enforcement authority. ATTACHMENT B DUTIES OF THE IOWA DEPARTMENT OF PUBLIC HEALTH 1. The Iowa Department of Public Health shall register all swimming pools and spas, provide for plan review and on-site inspections of new construction, conduct seminars and training sessions for operators, and disseminate information regarding health practices, safety measures, and operating procedures in accordance with 1351, the Iowa Code. 2. Trainina of local inspectors: The Iowa Department of Public Health shall provide training for local inspectors and public information brochures to facilitate compliance with 1351, the Iowa Code. 3. Review of the City of Dubuaue Proqram: The Iowa Department of Public Health shall annually provide for a certification inspection, which shall include a review of the rules, policies and procedures in the City of Dubuque program, and performance of local inspectors including on-site side by side inspections. The Iowa Department of Public Health shall advise City of its findings in writing. Follow-up shall be done on all deficiencies discovered in the City of Dubuque program. 4. Technical Assistance: The Department shall continue to provide technical information and consultation to the local program. 5. Compliance: The Iowa Department of Public Health will limit its involvement in compliance activities to audits and annual certification of the City of Dubuque program as well as review and comment on any proposed changes in the County's program unless: (I) (II) (III) The City specifically requests the Iowa Department of Public Health's involvement and the Iowa Department of Public Health agrees to accept responsibility; The Iowa Department of Public Health may initiate enforcement actions where specific City of Dubuque's program actions regarding a specific individual set of circumstances are determined by the Iowa Department of Public Health to not be timely or inappropriate. The Iowa Department of Public Health will, however, clearly state its position in writing and allow City of Dubuque 30 days to act prior to initiating any Iowa Department of Public Health enforcement actions; The Iowa Department of Public Health is enforcing the provisions of Rules 641-15.5 or 641-15.53(1351), lAC. 6. Interaovernmental Cooperation: In addition to the assistance and cooperation noted regarding specific issues above, the Iowa Department of Public Health will keep City of Dubuque informed of state and federal developments which may affect the swimming pool and spa program in the City of Dubuque. The Iowa Department of Public Health may also provide additional information requested by City of Dubuque in relation to the swimming pool and spa program. '. '~"~Iowa Department of Public Health ~~~ Thomas J. Vilsack Governor Sally J. Pederson Lt. Governor Mary Mincer Hansen, R.N., Ph.D. Director Memorandum of Understanding MOU-200S-PTT-DB between the Iowa Department of Public Health and Dubuque County Board of Health This Agreement is made and entered into by and between Dubuque County Board of Health, hereinafter called the CONTRACTOR and the Iowa Department of Public Health, hereinafter called DEPARTMENT. PURPOSE: It is the nmtual desire of the CONTRACTOR and the DEPARTMENT to assure the health and safety of the public by providing effective environmental health services. This agreement delegates the DEPARTMENT's inspection and enforcement authority with respect to tattoo establishments (Iowa Code 135.37; 641-22 lAC), tanning facilities (Iowa Code 136D; 641-46 lAC), and swimming pools and spas (Iowa Code 1351, 641-15 lAC) to the CONTRACTOR. I. The term of this Agreement shall be in effect from July 1,2004 until June 30,2005. To terminate this agreement within the effective dates, written notice to the other party shall be provided at least thirty (30) days prior to the intended date of termination. II. Contract Administrators Tom Newton, Director, Division of Health Protection and Environmental Health is the Authorized State Official for this agreement. The Authorized State Official must approve any changes in the tenns, conditions, or amounts specified in this contract. Negotiations concerning this contract should be referred to Ken Sharp at telephone (515) 281-7462 or kshaIp<w'idvh.state.ia.us . Mary Rose Corrigan has been designated by the CONTRACTOR to act as the Contract Administrator. This individual is responsible for financial and administrative matters of this contract. Negotiations concerning this contract should be referred to: Promoting and protecting the health of Iowans Lucas State Office Building, 321 E. 12th Street, Des Moines, IA 50319-0075.515-281-7689. www.idohstate.ia.us --. - --. ..", . --- --- -_0- . . Name Mary Rose Corrigan Business Name City of Dubuque Health Services Street Address 1300 Main St. City, State, Zip Dubuque, IA 52001 Telephone NunIDer 563-589-4181 E-mail address I. The DEPARTMENT agrees to: A. Register all swimming pools and spas and provide for plan review and on site inspections of new construction or reconstruction. B. Permit all tanning facilities, provide operator training material to the CONTRACTOR or their designee, and disseminate information regarding health practices, safety measures, and operating procedures in accordance with Iowa Code 136D. C. Permit all tattoo establishments and disseminate information regarding sanitation, infection control, and operating procedures in accordance with 641-22 lAC. D. Provide training for local inspectors, inspection form templates, and public information brochures to facilitate compliance with Iowa Code 135.37, 1351, and 136D. E. Provide technical assistance and consultation to the Dubuque County County program F. Review the CONTRACTOR's program at the DEPARTMENT's discretion. The review shall include a review of the rules, policies, and procedures of the CONTRACTOR's program; a review of inspection records; and may include a review of the Dubuque County inspector(s) performance. The DEPARTMENT shall advise the CONTRACTOR of its findings in writing, along with any corrective measures. Follow-up by the DEPARTMENT shall be done to verify correction of any identified deficiencies. G. Limit its involvement in compliance activities unless: I. The CONTRACTOR specifically requests the DEPARTMENT's involvement and the DEPARTMENT agrees to accept responsibility. II. The CONTRACTOR actions are determined by the DEPARTMENT to be inappropriate or untimely. However, the DEPARTMENT will state its position in writing and allow the CONTRACTOR thirty (30) days to act prior to the DEPARTMENT taking any further action. III. The DEPARTMENT is enforcing swimming pool and spa provisions defined in 641- 15.5 or 641-15.52 lAC. H. Keep the CONTRACTOR informed of developments that may affect any of the programs covered under this agreement. II. The CONTRACTOR agrees to: A. Provide the services outlined in this agreement in the following county(ies)/city: I. City ofDubuque(p), Dubuque County(P) NOTE: Counties/Cities listed above followed by parenthesis are counties were only certain inspection services are provided within that county. (P) indicates only pool/spa inspections are provided, (tt) indicates only tattoo and tanning inspections are provided. Otherwise, all services outlined in this agreement are expected to be provided in the counties listed. B. Employ adequate personnel to perform the services outlined in this agreement. Personnel employed for pool inspections shall meet the requirements defined in 641-15.13 lAC. Personnel employed for tattoo and tanning inspections shall have qualifications similar to an environmental specialist as defined by the Iowa Dept of Administrative Services. . . C. Link with the local board of health in each county where services are provided to assist the local board of health in performing its roles and responsibilities as defined in 641-77.3 lAC. D. Have the primary responsibility for the following activities: I. Operator testing, facility inspection, and enforcement of the tanning facility program as defined in 641-46 lAc. II. Inspection and enforcement of tattoo establishments as defined in 641-22 lAC. III. Annual and for-cause inspection of registered swimming pools and spas, and enforcement of the rules governing operation of swimming pools and spas (641 - 15.4 and 15.51 lAC). N. Provide consultation and information to any of the facilities outlined in this agreement to eliminate or minimize potential health and safety problem;. E. Submit the following reports to the department: I. Annual Report (July 1 - June 30) submitted not later than August 1 that shall include the following: 1. Monthly breakdown of the number of inspections, for each type of inspection. 2. Number of enforcement actions required to eliminate deficiencies, for each type of inspection. 3. Number of facilities closed, for each type of facility. II. Other reports as requested by the DEPARTMENT III. Manner of Financing A. The functions to be performed by the CONTRACTOR, under the provisions of this agreement, are to be financed by the CONTRACTOR at no obligation to the state. The CONTRACTOR shall collect and retain inspection fees pursuant to Iowa Code Chapters 135.37, 1351, and 136D and Iowa Administrative Code Chapters 641-15, 641-22, and 641-46. N. It is nmtually understood and agreed that: A. This agreement can be amended only by the nmtual written consent of both parties. B. Any use of the DEPARTMENT'S name, logo, or other identifier must have prior written approval from the DEPARTMENT. C. The parties to this agreement shall attempt to mediate disputes which arise under this agreement by engaging in mediation with a nmtually-agreed upon mediator. Each party shall bear 50% of the costs of such mediation. In the event the parties are unable to reach agreement, the parties shall submit their dispute to binding arbitration by a board of arbitration as provided for in Iowa Code section 679A.19 BY parties have signed their names effective the day and year first above written. DATE: t?/ö,1 e County Board of Health IOWA DEPARTMENT OF PUBLIC HEALTH BY DATE: Tom Newton, Director Division of Health Protection & Environmental Health SUBCONTRACT AGREEMENT FOR CHILDHOOD LEAD POISONING PREVENTION SERVICES BETWEEN DUBUQUE COUNTY BOARD OF HEALTH AND THE CITY OF DUBUQUE, IOWA WHEREAS, the Dubuque County Board of Health (County Board), as Contractor, has entered into an Agreement (the Agreement) with the Iowa Department of Public Health to perform childhood lead poisoning prevention services as set forth in the Agreement, a copy of which is attached hereto; and WHEREAS, County Board desires to enter into a subcontract with the City of Dubuque (City) to perform the services required by the Agreement and City desires to provide such services through its Health Services Department. NOW, THEREFORE, IT IS AGREED BY AND BETWEEN THE PARTIES AS FOLLOWS: 1. City shall perform all of the services required of the Contractor in the Agreement. 2. County Board shall pay City for its services in the same manner as County Board as Contractor will be paid for its services under the Agreement. Signed and dated the - day of ,2004. Michael C. Van Milligen City Manager AGREEMENT BETWEEN THE CITY OF DUBUQUE, IOWA, AND THE VISITING NURSE ASSOCIATION FOR THE CHILDHOOD LEAD POISONING PREVENTION PROGRAM (CLPPP) Now on this 1 st day of July 2004, it is agreed by and between the City of Dubuque, Iowa, (City) and the Dubuque Visiting Nurse Association (VNA) as follow: A. B. C. 4. TERM. The term of this Agreement shall be from the 1 st day of July 2004, through the 30th day of June 2005. CITY'S RESPONSIBILITIES. City agrees that it will provide the following services for the CLPPP: 1. Submit quarterly reports and other reporting requirements as requested to the Iowa Department of Public Health (IDPH) and the Centers for Disease Control and Prevention. (CDC). 2. Provide for environmental investigations and environmental case management for lead abatement\lead hazard reduction in housing units in the city of Dubuque, Iowa, and Dubuque County. 3. Provide compensation to the VNA during the term of this Agreement not to exceed $14,280.00 for the performances of VNA's responsibilities as set forth herein. 4. Oversee and direct medical case management activities through verbal and written direction. VNA'S RESPONSIBILITIES. VNA agrees to provide the following services for CLPPP during the term of this Agreement for the agreed compensation: 1. Provide written quarterly reports on lead-related activities utilizing the Iowa Quarterly Report Narrative Outline. 2. Provide computer documentation of medical case management and related activities into City's lead database system, STELLAR. 3. Provide blood lead screening and medical case management for follow-up testing for children in the city of Dubuque following the recommendations of the IDPH and the City of Dubuque Health Services Department. Assist City with providing public education, lead coalition development and activities, and outreach to the City of Dubuque residents about childhood lead poisoning. 5. Conduct home visits as needed to families\residents in order to provide medical case management services. 1 7. 8. 9. 10. 6. Provide education and medical case management of children with confirmed blood lead levels greater than or equal to 15 ¡Jg\dL. Medical case management includes: assurance that children are being screened\retested for lead and case managed according to Iowa Department of Public Health requirements; assurance that children and parents receive nutritional counseling and educational materials; educate parents and families about major sources of lead and how to prevent poisoning; assistance in interpreting blood lead levels; refer all children with confirmed blood lead levels greater to or equal to 20 ¡Jg\dL to Keystone Area Education Agency for appropriate developmental testing, evaluation and assessment; and provide information about lead testing and follow-up, available services, and resources for lead- poisoned children. Provide information about lead poisoning and available services to local pediatric health care providers. Participate with City in securing additional funding for childhood lead poisoning prevention activities. Provide monthly work activity reports and invoices to the City Health Services Department outlining services performed, by the 7th day of the month following the previous month. Work towards achieving the program performance standards in conjunction with the City's CLPPP, as outlined in the City's IDPH contract, Exhibit III. D. INSURANCE. VNA agrees to provide insurance as set forth in the attached Insurance Schedule. E. INDEMNIFICATION. City agrees to save, defend, indemnify and hold harmless VNA from and against any and all claims which may be made against VNA arising out of this Agreement which are the result of the sole negligence of City, its officers, agents or employees. VNA agrees to defend, hold harmless and indemnify City from and against any and all claims which may be made against City arising out of this Agreement which are the sole negligence of VNA, its officers, employees or agents. F. TERMINATION. Either party may terminate this Agreement by giving sixty (60) days written notice to the other party. 2 CITY OF DUBUQUE. IOWA BY: Michael C. Van Milligen City Manager VISITING NURSE ASSOCIATION BY: 3 Kathy Ripple Administrative Director SCHEDULE C INSURANCE REQUIREMENTS FOR PROFESSIONAL SERVICES 1. All policies of insurance required hereunder shall be with an insurer authorized to do business in Iowa. All insurers shall have a rating of A of better in the current A.M. Best Rating Guide. 2. All policies of insurance shall be endorsed to provide a thirty (30) day advance notice of cancellation to the City of Dubuque if cancellation is prior to the expiration date. This endorsement supersedes the standard cancellation statement on the Certificate of Insurance. 3. shall furnish a Certificate of Insurance to the City of Dubuque, Iowa for the coverage required in Paragraph 6 below. Such Certificates shall include copies of the following endorsements: a) Thirty day notice of cancellation to the City of Dubuque. b) Commercial General Liability policy is primary and non-contributing. c) Commercial General Liability additional insured endorsement. d) Governmental Immunities Endorsement. e) Waiver of Recovery under workers compensation. shall also be required to provide Certificates of Insurance of all subcontractors and all sub-sub contractors who perform work or services pursuant to the provisions of this contract. Said certificates shall meet the same insurance requirements as required of 4. Each certificate shall be submitted to the contracting department of the City of Dubuque. 5. Failure to provide minimum coverage shall not be deemed a waiver of these requirements by the City of Dubuque. Failure to obtain or maintain the required insurance shall be considered a material breach of this agreement. 6. Contractor shall be required to carry the following minimum coverage/limits or greater if required by law or other legal agreement: a) COMMERCIAL GENERAL LIABILITY General Aggregate Limit Products-Completed Operations Aggregate Limit Personal and Advertising Injury Limit Each Occurrence Limit Fire Damage Limit (anyone occurrence) Medical Payments $2,000,000 $1,000,000 $1,000,000 $1,000,000 $ 50,000 $ 5,000 This coverage shall be written on an occurrence, not claims made, form per project. All deviations or exclusions from the standard ISO commercial general liability form CG 0001 or Businessowners BP 0002 shall be clearly identified. Governmental Immunity endorsement identical or equivalent to form attached. An additional insured endorsement identical or equivalent to ISO Form CG 2026 and include as additional insureds: "The City of Dubuque, including all its elected and appointed officials, all its employees and volunteers, all its boards, 4 commissions and/or authorities and their board members, employees, and volunteers." b) WORKERS COMPENSATION & EMPLOYERS LIABILITY Statutory for Coverage A Employers Liability: $100,000 each accident $100,000 each employee-disease $500,000 policy limit-disease Policy shall include an endorsement waiving right of recovery against City of Dubuque. c) PROFESSIONAL LIABILITY: d) UMBRELLA/EXCESS LIABILITY $1,000,000 Coverage to be determined on a case-by-case basis by Finance Director. 5 POLICY NUMBER COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGAN IZA TION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person Or Organization: The City of Dubuque, including all its elected and appointed officials, all its employees and volunteers, all its boards, commissions and/or authorities and their board members, employees, and volunteers. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. Coevriaht. Insurance Services Office. Inc. 1994 CG 20 2611 85 6 CITY OF DUBUQUE, IOWA GOVERNMENTAL IMMUNITIES ENDORSEMENT 1. Nonwaiver of Governmentallmmunitv. The insurance carrier expressly agrees and states that the purchase of this policy and the including of the City of Dubuque, Iowa as an Additional Insured does not waive any of the defenses of governmental immunity available to the City of Dubuque, Iowa under Code of Iowa Section 670.4 as it is now exists and as it may be amended from time to time. 2. Claims Coveraae. The insurance carrier further agrees that this policy of insurance shall cover only those claims not subject to the defense of governmental immunity under the Code of Iowa Section 670.4 as it now exists and as it may be amended from time to time. Those claims not subject to Code of Iowa Section 670.4 shall be covered by the terms and conditions of this insurance policy. 3. Assertion of Government Immunity. The City of Dubuque, Iowa shall be responsible for asserting any defense of governmental immunity, and may do so at any time and shall do so upon the timely written request of the insurance carrier. 4. Non-Denial of Coveraae. The insurance carrier shall not deny coverage under this policy and the insurance carrier shall not deny any of the rights and benefits accruing to the City of Dubuque, Iowa under this policy for reasons of governmental immunity unless and until a court of competent jurisdiction has ruled in favor of the defense(s) of governmental immunity asserted by the City of Dubuque, Iowa. No Other Chanae in Policv. The above preservation of governmental immunities shall not otherwise change or alter the coverage available under the policy. 7 Iowa Department of Public Health Sally j. Pederson Lt. Governor CONTRACT #: 5885LP05 PROJECT TITLE: Childhood Lead Poisoning Prevention Program FUNDING SOURCE OF lDPH: FEDERAL: $19,730 -- 100.00% STATE: $0 -- 0.00% OTHER: -- 0.00% FEDERAL CATALOG#: 93.197 MATCHREQUlRED: YESD NOrg] NAD MAIL REPORTS TO: Rita Gergely, Chief Bureau of Lead Poisoning Prevention Division of Environmental Health and Health Statistics Iowa Department of Public Health 321 East 12th Street Lucas State Office Building Des Moines, 1A 50319-0075 Mary Mincer Hansen. R.N., Ph.D. Director PROJECT PERIOD: July 1,2004 to June 30, 2005 CONTRACT PERIOD: July 1, 2004 to June 30, 2005 CONTRACT AMOUNT: $19,730 FEDERAL TAX lD#: 426004597 CONTRACTOR: Dubuque County Board of Health c/o City of Dubuque Health Services Department, 1300 Main City Hall Annex Dubuque 1A 52001 CONTRACT ADMINISTRATOR INFORMATION NAME: Mary Rose Corrigan PHONE: 563-589-4181 FAX: 563-589-4299 E-MAIL: health@cityofdubuque.org The Contractor agrees to perform the work and to provide the services described in the Special conditions for the consideration stated herein. The duties, rights, and obligations of the parties to this contract shall be governed by the Contract Documents, which include the Special Conditions, General Conditions, Request for Proposal and Application. The Contractor has reviewed and agrees to the General Conditions effective September 22, 2003, as posted on the Department's web at www.idph.state.ia.us (click on Availability of Funds Link) or as available by contacting Rita Gergely at 515/242-6340. The parties hereto have executed this contract on the day and ar I t For and on behalf of the Department: By: Tom Newton, Director, Division of Environmental Health and Health Statistics Date actor: Nick Goodm , Chair, Board of Health Date ,/.n ;:/ I , Promoting and protecting the health of Iowans Lucas State Office Building, 321 E. 12'" Street, Des Moines, IA 50319-0075 . 515-281-7689 . www.idph.state.ia.us DEAF RELAY (Hearing or Speech Impaired) 711 or I 800-735-2942 SPECIAL CONDITIONS FOR CONTRACT #S88SLPOS ARTICLE I - IDENTIFICATION OF PARTIES. This contract is entered into by and between the Iowa Department of Public Health (hereinafter referred to as the DEPARTMENT) and the CONTRACTOR, as identified on the contract face sheet. ARTICLE II - IDENTIFICATION OF AUTHORIZED STATE OFFICIAL: Tom Newton, Director, Division of Environmental Health and Health Statistics, is the Authorized State Official for this contract. Any changes in the terms, conditions, or amounts specified in this contract must be approved by the Authorized State Official. Negotiations concerning this contract should be referred to Rita Gergely, Chief, Bureau of Lead Poisoning Prevention, 515/242-6340 ARTICLE III - DESIGNATION OF CONTRACT ADMINISTRATOR AND KEY PERSONNEL Mary Rose Corrigan has been designated by the CONTRACTOR to act as the Contract Administrator. This individual is responsible for financial and administrative matters of this contract. Negotiations concerning this contract should be referred to Mary Rose Corrigan; telephone 563-589-4181, The primary agency subcontracted to carry out the responsibilities of the contract is: City of Dubuque Health Services Department. The following individual(s) shall be considered key personnel: ARTICLE IV - STATEMENT OF CONTRACT PURPOSE The purpose of this contract is to provide funds for the contractor to conduct childhood lead poisoning prevention activities as specified in Article V, Description of Work and Services. ARTICLE V - DESCRIPTION OF WORK AND SERVICES: The CONTRACTOR shall conduct childhood lead poisoning prevention services as specified in this article. DEFINITIONS "Blood lead testing" means taking a capillary or venous sample of blood and sending it to a laboratory to determine the level oflead in the blood. "Capillary" means a blood sample taken from the finger or heel for lead analysis. "Care coordination" means the process of linking the service system to the recipient and/or family, and coordination of the various elements in order to achieve a successful outcome. "CDC" means the Centers for Disease Control and Prevention. "Certifìed elevated blood lead (EEL) inspection agency" means an agency that has met the requirements of 641-70.5(135) and that has been certified by the department. "Certified elevated blood lead (EEL) inspector/risk assessor" means a person who has met the requirements of641-70.5(135) for certification or interim certification and who has been certified by the department. "Chelation" means the administration of medication that binds lead so that it can be removed from the body. "Child health contractor" means an agency that has a contract with the Iowa Department of Public Health for the Title V Child Health program. "Childhood Lead Poisoning Prevention Program (CLPPP) service area" means the geographic area for which the CLPPP has agreed to provide CLPPP services. "CLPPP" means childhood lead poisoning prevention program. "Complete medical evaluation" means a history, physical examination, and testing for iron status as described in Chapter 7 of Preventing Lead Poisoning in Young Children, CDC, October 1991. "Data management" means all actions taken by the contractor to manage blood lead data and case management data. This includes, but is not limited to, entering blood lead test results for all individuals under the age of 16 years in the CLPPP service area who receive blood lead testing from the CLPPP or any other provider in the STELLAR database, documenting aU case management actions such as contact with the family or provider, EBL inspection, lead hazard remediation, home nursing or outreach visits, nutrition evaluations, and developmental assessments in the STELLAR database, and providing all STELLAR reports required by this contract. "Developmental testing" means testing done by the local Area Education Agency to determine whether a child is developmentaUy delayed. "Education and outreach" means seeking out and providing information regarding childhood lead poisoning to members of populations who are at high risk for lead poisoning and those who work for agencies that provide service to these high-risk populations; members of the general public, including homeowners, landlords, Realtors, and members of community organizations, and health professionals and para- professionals, including physicians, nurses, and laboratory technicians. "Elevated blood lead (EEL) child" means any child who has had one venous blood lead level greater than or equal to 20 micrograms per deciliter (~g/dL) or at least two venous blood lead levels of 15 to 19 ~g/dL. "Elevated blood lead (EEL) inspection" means an inspection to determine the sources of lead exposure for an elevated blood lead (EBL) child and the provision within ten working days of a written report explaining the results of the investigation to the owner and occupant of the residential dweUing or child-occupied facility being inspected and to the parents of the elevated blood lead (EBL) child. "Elevated blood lead (EEL) inspection agency" means an agency that employs or contracts with individuals who perform elevated blood lead (EBL) inspections. Elevated blood lead (EBL) inspection agencies may also employ or contract with individuals who p¡;:rform other lead-based paint activities. "Environmental case management" means providing elevated blood lead (EBL) inspections in all dwellings associated with an EBL child and assuring that lead hazards identified at these dwellings. "Follow-up blood lead testing" means blood lead testing that is conducted after a child has had at least one capillary or venous blood lead level greater than or equal to 10 ¡tgidL. "Home nursing or outreach visit" means a home visit conducted by a nurse or social worker to provide information to the caregiver of a lead-poisoned child regarding the health effects of lead poisoning, the importance of good housekeeping and nutrition, and the importance of follow-up blood lead testing and to assess the overall situation of the child and family to determine whether the child and/or family should be referred for additional services. "Lead-based paint hazard" means hazardous lead-based paint, a dust-lead hazard, or a soil-lead hazard as defined in 641-Chapter 70. "Lead hazard remediation" means the control of lead hazards identified in the EBL inspection through interim controls, renovation and remodeling, or lead abatement. "Local board of health " means a county, district, or city board of health. "Local coalition" means a group convened by the contractor to address the issue of childhood lead poisoning in the CLPPP service area. The local coalition should be composed of physicians, nurses, housing officials, parents, contractors, and representatives of neighborhoods where homes are being renovated. "Medical case management" means all services necessary to evaluate the health and development of a child with a blood lead level greater than or equal to 10 ¡tgidL and to treat any conditions identified in the evaluation. Medical case management includes, but it not limited to, follow-up blood lead testing, medical evaluation, home nursing or outreach visits, chelation, nutrition evaluation, developmental assessment, and care coordination. "Nutrition evaluation" means an evaluation conducted by a dietician to determine whether a child is receiving a well-balanced and age-appropriate diet, with particular attention to the child intake of Vitamin C, iron, and calcium. "Quarterly narrative report" means a report of the contractor's childhood lead poisoning prevention activities for the quarter that is developed according to guidelines provided by the department and is provided to the department by the deadlines given in Article VII. "Quarterly update for supervisory database" means an extract of the contractor's STELLAR database that is provided electronically to the department by the deadlines given in Article VI. "Referral" means to direct the family of a lead-poisoned to a service for the family or the child and to follow-up to assure that the family actually received the service. "STELLAR" means the Systematic Tracking of Elevated Lead Levels and Remediation database, which is provided by CDC at no charge. "STELLAR Lab Batch" means the procedure ill STELLAR that processes blood lead tests and sets dates for follow-up blood lead tests, opens medical cases, and opens environmental cases. "STELLAR quarterly report" means the procedure in STELLAR that compiles the contractor's activities for the quarter into a data file that is submitted to the department electronically by the deadlines given in Article VII. "Venous" means a blood sample taken from a vein in the arm for lead analysis. CLPPP SERVICE AREA The CLPPP service area is Dubuque County. REQUIRED SERVICES The contractor is responsible for blood lead testing, data management, environmental case management, medical case management, education and outreach, and the local coalition within its service area. The contractor shall develop written protocols to describe how each of these services will be provided. The contractor may use templates provided by the department to develop these protocols. BLOOD LEAD TESTING The contractor shall assure that the State of Iowa Plan for Childhood Blood Lead Testing (January 2004) is implemented within the CLPPP service area. The contractor shall assure that medical providers conduct blood lead testing according to this plan. The contractor may also conduct blood lead testing. The contractor shall provide a written notice of the results of blood lead testing to the caregivers of all children tested by the contractor. The written notice shall include information regarding the meaning of the blood lead test result and the date when the child should be tested again. The contractor shall provide a written notice of the results of blood lead testing to the caregivers of all children in the CLPPP service area who have blood lead levels greater than or equal to 10 ¡tg/dL, regardless of whether the contractor did the testing. The written notice shall include information regarding the meaning ofthe blood lead test result, actions that the parents can take to reduce the child's blood lead level, and the date when the child should be tested again. DATA MANAGEMENT The contractor shall conduct data management as specified in this contract. The contractor shall notifY the department within 10 working days of assigning STELLAR data entry duties to a new staff person. Contractor shall assure the department that new data entry staff has received appropriate training or work within the department to assure that new data entry staff receives appropriate training. The contractor shall install STELLAR on a computer network consisting of at least two computers that are linked to the same server. The contractor shall allow the DEPARTMENT and other agencies providing medical and environmental case management oflead-poisoned children in the CLPPP service area to access the main STELLAR database via the software, PC Anywhere, or another software package approved in advance by the DEPARTMENT. This software shall be installed on a computer that is continuously available for the DEPARTMENT and other agencies for access. The CONTRACTOR may request that the DEPARTMENT waive the requirement that STELLAR be installed on a network and that a computer be continuously available for the DEPARTMENT and other agencies to access. The CONTRACTOR shall make this request in writing. The DEP ARTMEþTT will approve or deny these requests on a case-by-case basis. The contractor shall enter the results of blood lead testing for all individuals under the age of 16 years in the CLPPP service area who receive blood lead testing from the CLPPP or any other provider in the STELLAR database. The contractor shall document all case management actions taken by the contractor such as contact with the family or provider, EBL inspection, lead hazard remediation, home nursing or outreach visits, nutrition evaluations, and developmental assessments in the STELLAR database and shall assure that all CLPPP subcontractors also document all case management actions that they taken in STELLAR. The contractor shall enter blood lead test results and case management actions into STELLAR on at least a weekly basis. The contractor shall run STELLAR Lab Batch at least every two weeks and shall forward case information to other agencies providing medical and environmental case management in the CLPPP service area at least every two weeks. The contractor shall provide all STELLAR reports by the deadlines given in this contract. The DEPARTMENT will periodically review the CONTRACTOR STELLAR database for errors and notifY the CONTRACTOR of errors that must be corrected. The CONTRACTOR shall correct the errors by the date specified in the notification and shall implement quality control measures to prevent data entry errors. ENVIRONMENTAL CASE MANAGEMENT The contractors shall maintain certification of individual inspectors as elevated blood lead (EBL) inspector/risk assessors and agency certification as an elevated blood lead level (EBL) inspection agency. The contractor shall be enrolled as a Medicaid provider for EBL inspection services and shall recover reimbursement from Medicaid for EBL inspections and use the reimbursement as program income. The contractor shall conduct elevated blood lead (EBL) inspections for any child under the age of six years who has had one venous blood lead level greater than or equal to 20 J.lg/dL or at least two venous blood lead levels of 15 to 19 J.lg/dL. EBL inspections shall be conducted for all addresses associated with the child and for all addresses that the child moves to after the case is initially reported until the child has had one blood lead level less than 10 J.lg/dL or three blood lead levels less than 15 J.lg/dL. EBL inspections shall be conducted within the following times: . Two venous blood lead levels of 15 to 19 J.lg/dL - within 4 weeks after the report. . Venous blood lead level of20 to 44 J.lg/dL - within 2 weeks after the report . Venous blood lead level of 45 to 69 J.lg/dL - within 1 week after the report . Venous blood lead level greater than or equal to 70 J.lg/dL - within 2 days after the report. The contractor shall document in STELLAR the reason why the contractor was unable to complete any inspection required by this contract. The contractor shall contact the occupants and/or owners of dwellings where lead hazards have been identified within 30 days of the initial inspection to check their progress towards making the dwelling lead- safe. The contractor shall follow up on all dwellings where lead hazards were identified, but lead hazard remediation has not been completed, at least once every six months until lead hazard remediation is completed. The contractor shall continue to follow up on all of these dwellings until lead hazard remediation is completed, regardless of whether the dwellings are owner-occupied or rental and regardless of changes in ownership. The contractor shall not close an address associated with a lead-poisoned child where lead hazards have been identified unless the lead h~ard remediation has been completed unless permission is obtained in advance from the DEPARTMENT. The contractor shall, to the extent possible, assist families who have lead-poisoned children in locating resources for lead hazard remediation and/or alternative housing. MEDICAL CASE MANAGEMENT The contractor shall conduct medical case management as specified in this contract. The contractor shall be enrolled as a Medicaid provider for services that can be reimbursed by Medicaid and shall recover reimbursement from Medicaid for medical case management services and use the reimbursement as program income. Follow-up blood lead testine: The contractor shall assure that providers in the CLPPP service that conduct blood lead testing provide follow-up blood lead testing for children under the age of six years within the timelines listed below. The contractor may provide this follow-up blood lead testing. ConfirmatOlY venous blood lead testing . Capillary blood lead level of 15 to 19 .1g!dL - within 4 weeks after the report. . Capillary blood lead level of 20 to 44 .1g!dL - within 1 week after the report . Capillary blood lead level of 45 to 69 .1g!dL - within 48 hours after the report . Capillary blood lead level greater than or equal to 70 .1g!dL - immediately- Follow-up testing after an elevated blood lead level for a child who has not been chelated . Capillary or venous blood lead level of 10 to 14 .1g!dL - within 3 months. After two levels less than 10 .1g!dL or three levels less than 15 .1g!dL, testing should follow the routine testing schedule for high-risk children. . Venous blood lead level ofl5 to 19 .1g/dL -within 3 months. . Venous blood lead level of 20 to 44 .1g!dL - within 4 to 6 weeks. . Venous blood lead level greater than or equal to 45 .1g!dL - immediately Follow-up testin¡! for a child who has been chelated . At the end of chelation. . Depending on the blood lead level, 7 to 21 days after the end of chelation. The results of this test will determine the need for additional chelation and the schedule for additional blood lead testing. Medical evaluations The contractor shall assure that providers in the CLPPP provide conduct medical evaluations for children under the age of six years within the following timelines: . Venous blood lead level of20 to 44 .1g/dL - Refer within 48 hours after the report so that the service is received within 5 days. . Venous blood lead level of 45 to 69 .1g!dL - Refer within 24 hours after the report so that the service is received within 48 hours. . Venous blood lead level greater than or equal to 70 ¡¡.g/dL - Refer for emergency medical evaluation. Home nursinl!: or outreach visits The contractor shall provide home nursing or outreach visits for children under the age of six years according to the following timelines: . Venous blood lead level of 15 to 19 ¡¡.g/dL - within 4 weeks after the report. . Venous blood lead level of 20 to 44 ¡¡.g/dL - within 2 weeks after the report . Venous blood lead level of 45 to 69 ¡¡.g/dL - within 1 week after the report . Venous blood lead level greater than or equal to 70 ¡¡.g/dL - within 2 days after the report. Chelation The contractor shall assure that children with two venous blood lead levels greater than or equal to 45 ¡¡.g/dL receive chelation. Nutrition evaluation The contractor shall assure that children under the age of six years with a venous blood lead level greater than or equal to 15 ¡¡.g/dL receive a nutrition evaluation according to the following timelines: . Venous blood lead level of 15 to 19 ¡¡.g/dL - within 4 weeks after the report. Venous blood lead level of 20 to 44 ¡¡.g/dL - within 2 weeks after the report Venous blood lead level of 45 to 69 ¡¡.g/dL - within 1 week after the report Venous blood lead level greater than or equal to 70 ¡¡.g/dL - within 2 days after the report. . . . The contractor shall contact the DEPARTMENT for assistance if access to a dietician cannot be assured for children under the age of six years with a venous blood lead level greater than or equal to 15 ¡¡.g/dL. Developmental assessment The contractor shall assure that children under the age of six years with a venous blood lead level greater than or equal to 20 ¡¡.g/dL receive a developmental assessment according to the following timelines: . Venous blood lead level of 20 to 44 ¡¡.g/dL - Refer within 2 weeks after the report. . Venous blood lead level of 45 to 69 ¡¡.g/dL - Refer within 1 week after the report . Venous blood lead level greater than or equal to 70 ¡¡.g/dL - Refer within 2 days after the report. Care coordination The contractor shall provide care coordination or refer the family to the local child health contractor for this servIce. Medical Case Closure Guidelines Medical cases shall be closed only in the following circumstances: 1. A child has had two consecutive blood lead levels less than 10 ¡¡.g/dL or three consecutive blood lead levels less than 15 ¡¡.g/dL after the initial elevated blood lead level. 2. A child has had a capillary false positive blood lead level; that is, a capillary or venous blood lead level less than 10 ¡¡.g/dL immediately after a single capillary blood lead level greater than or equal to 15 ¡¡.g/dL. 3. A child has reached the age of six years and has a blood lead level less than 20 lg/dL. 4. A child has moved out of the CLPPP service area. The contractor shall immediately notifY the appropriate local CLPPP agency in the area to which the child has moved and provide copies of all environmental and medical case management records to the appropriate local CLPPP agency. CIDLDREN OVER THE AGE OF SIX YEARS The contractor shall contact the department for specific case management guidelines for a child over the age of six years who has a venous blood lead level greater than or equal to 20 lg/dL. EDUCATION AND OUTREACH The contractor shall provide education and outreach regarding childhood poisoning in the CLPPP service area. LOCAL COALITION The contractor shall establish a local coalition for the CLPPP service area. The coalition may be a subgroup/work group of a larger umbrella coalition. However, participation in an umbrella coalition does not meet this requirement unless a specific subgroup has been formed to deal with lead poisoning prevention in the community. The coalition shall include citizens who are not part of agency (Health, Housing, Human Services, etc.) staff that participate in the CLPPP. ARTICLE VI - PERFORMANCE MEASURE Not applicable. ARTICLE VII - REPORTS The CONTRACTOR shall prepare and submit the following reports to the DEPARTMENT on forms and/or in the format approved by the DEPARTMENT: Report Claim Voucher Number 1 original Date Due Within 45 days of month of expenditure Expenditure Report 1 original Within 45 days of month of expenditure Quarterly Narrative Report 1 Electronic 10-25-2004 1-25-2005 4-25-2005 7-25-2005 STELLAR Quarterly Report 1 Electronic 10-25-2004 1-25-2005 4-25-2005 7-25-2005 ARTICLE VIII- BUDGET: The total approved budget for this contract period is detailed in Exhibit 1. Services will be reimbursed at a flat fee as specified on Exhibit 1 up to the amount of the contract. The CONTRACTOR may change the number of any deliverable that the DEPARTMENT will reimburse under this contract only after filing a written request for the revision and receiving written approval for this change. ARTICLE IX: PAYMENTS 1. The DEPARTMENT provides contractual payments on the basis of reimbursement of actual expenses in accordance with Iowa Code 421.40. 2. The DEPARTMENT will not reimburse travel amounts in excess of limits established by Iowa Department of Revenue and Finance. a. Instate maximum allowable amounts for food are $8.00/brealcfast, $9.oo/lunch and $18.00/dinner; lodging maximum $68 plus taxes per night and mileage maximum of$.29 per mile. Out of state maximum allowable amounts for meals are available upon request. There is no restriction on airfare or lodging but the incurred expenditures are to be reasonable. b. 3. Final payment may be withheld until all contractually required reports have been received and accepted by the DEP AR TMENT. At the end of the contract period, unobligated contract amount funds shall revert to the DEPARTMENT. ARTICLE X - LOCAL BOARD OF HEALTH LINKAGE: 1. As a condition ofthe contract, the CONTRACTOR shall assure linkage with the local board of health in each county where services are provided. The CONTRACTOR will assure that the local board of health has been actively engaged in planning for, and evaluation of, services. It will also maintain effective linkages with the local board of health, including timely and effective communications and ongoing collaboration. 2. All work plan revisions must be approved by the DEPARTMENT prior to implementation. ARTICLE XI - ADDITIONAL CONDITIONS 1. Funds must be made available to reimburse subcontractor expenses no later than August 1, 2004. 2. Funds may not be spent for indirect costs, chelation or other medical treatment of lead poisoning, lead hazard remediation, or blood lead analysis. 3. On January 1,2005, April 1, 2005, and June 1,2005, the DEPARTMENT may amend the contract to revert funds that are estimated to be unused to the D EP AR TMENT and to reallocate the funds to contractors with demonstrated special needs for childhood lead poisoning prevention services. 4. Final payments may be withheld ifthe agency or personnel employed by the agency are not in compliance with Iowa Administrative Code Chapter 641-70, Lead Professional Certification. 5. The contractor must check Internet e-mail at least once each week for lead poisoning prevention updates sent out by the DEPARTMENT. 6. XRF analyzers that were originally purchased, in part or in whole, with Iowa Department of Public Health grant funds, are to be shared with other elevated blood lead (EBL) inspector/risk assessors that have a contract with the Childhood Lead Poisoning Prevention program. This sharing is to be at no cost other than their travel to pick up and deliver the machine. Programs are strongly encoumged to also share the XRF analyzers with government and private, non-profit housing agencies that employ appropriately certified inspector/risk assessors. Any fees received for sharing the machine with government and private, non-profit housing agencies are considered program income that shall be returned to the lead program and used to enhance lead program efforts. 7. If the CONTRACTOR receives third-party reimbursement for a childhood lead poisoning prevention service reimbursed by the DEPARTMENT and the total reimbursement exceeds the CONTRACTOR'S cost to provide the service, then the CONTRACTOR shall document how the excess reimbursement has been used to enhance lead program efforts. EXHIBIT 1 '- EXPENDITURE REPORT FOR THE MONTH OF - - - - -- --. ~.,. ~uuuqu~ ,-uwlty ooaro or Health CONTRACT #5885LP05 CONTRACT PERIOD: July 1,2004 to June 30, 2005 Reimbursable Budgeted Budgeted Budgeted Number Reimbursement Number Reimbursement Balance Number Rate (A) Total (B) Completed for for Month Completed to Date (D) (B-D) Month (C) (Ax C) to Date Children Tested for Lead Poisoning (under 6 years) 2,850 $1 $2,850 $ $ $ Child CONTC or ACTIO event 342 $10 $3.420 $ $ $ Non-Medicaid Home Nursing Visits 26 $70 $1,820 $ $ $ RefeJTals for Nutrition Counseling 26 $10 $260 $ $ $ RefeJTals for Developmental Testing 13 $10 $130 $ $ $ Initial Inspection Events 13 $400 $5,200 $ $ $ EBL Investigation Follow-ups 75 $30 $2,250 $ $ $ Completed Lead Hazard Remediations 8 $50 $400 $ $ $ Coalition Meeting Hours 8 $40 $320 $ $ $ Education and Outreach Hours 56.00 $40 $2,240 $ $ $ Running Lab Batch 24 $10 $240 $ STELLAR Quarterly Report Submitted on Time 4 $75 $300 NaITative Quarterly Report Submitted on Time 4 $75 $300 TOTAL NA NA $19,730 NA NA 'NT IDPH NOTE: Pay from 1352. DOCUMENTATION OF PROGRAM INCOME Amount for Amount Month to Date Program Income Earned $ $ Program Income Received $ $ Program Income Expended $ $ SIGNATURE: I certify that no funds have been spent on chelation or other medical treatment oflead poisoning, lead hazard remediation, collection of blood lead samples, or blood lead analysis. DATE: