Health Homes & Childhood Lead Poisoning Prevention Program Contracts/SubcontractsTHE CITY OF
Dui
Masterpiece on the Mississippi
TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
Dubuque
band
AI -America City
r
2007 • 2012 • 2013
SUBJECT: Iowa Department of Public Health Childhood Lead Poisoning and Healthy
Homes Funding and Agreement with the Visiting Nurse Association and
the Dubuque County Board of Health
DATE: July 1, 2014
Public Health Specialist Mary Rose Corrigan is recommending approval of a contract
with the Dubuque County Board of Health and the Iowa Department of Public Health for
continued funding of the Childhood Lead Poisoning Prevention Program and a renewed
agreement with the Visiting Nurse Association for services related to the Childhood
Lead Poisoning Prevention Program and Healthy Homes Program.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
1„i1144 .,
Mic ael C. Van Milligen
MCVM:jh
Attachment
cc: Barry Lindahl, City Attorney
Cindy Steinhauser, Assistant City Manager
Teri Goodmann, Assistant City Manager
Mary Rose Corrigan, Public Health Specialist
THE CITY OF
Dui
Masterpiece on the Mississippi
TO: Mike Van Milligen, City Manager
FROM: Mary Rose Corrigan, Public Health Specialist
Dubuque
bard
All -America City
r
2007 • 2012 • 2013
SUBJECT: Iowa Department of Public Health (IDPH) Childhood Lead Poisoning and
Healthy Homes Funding and Agreement with the Visiting Nurse Association
(VNA) and the Dubuque County Board of Health
DATE: June 18, 2014
INTRODUCTION
This memorandum provides information regarding a contract with the Dubuque County
Board of Health and the Iowa Department of Public Health (IDPH) for continued funding of
the Childhood Lead Poisoning Prevention Program (CLPPP) and a renewed agreement
with the VNA for services related to the CLPPP and Healthy Homes Program.
BACKGROUND
In February 1994, the City Council approved a grant agreement authorizing the Health
and Housing Services Departments to contract with the Iowa Department of Public Health
for environmental follow-up and medical case management for children with lead
poisoning according to the Iowa Department of Public Health guidelines. The original
funding contract has been renewed annually. The latest contract ended June 30, 2014.
DISCUSSION
The Iowa Department of Public Health contracts with local Boards of Health for distribution
of their funds. This allows local Boards of Health to monitor public health funding, avoid
duplication of services and assure community health needs are addressed (see attached
contract.)
The subcontracted funds will allow the Health and Housing Services Departments to
provide additional follow-up of lead poisoned children through contracted nursing services
provided by the Dubuque Visiting Nurse Association, education for employees, and
monies to do outreach and education in targeted neighborhoods regarding lead poisoning
and healthy homes activities.
1
The contract also includes program performance standards, which we currently strive to
achieve through our existing protocols and outreach programs. The grant funds will be
reimbursed based on the specific activities outlined in the budget.
BUDGET IMPACT
The FY15 budget anticipated funding of $7,000. The contract is for $6,454, due to State
and Federal budget reductions. The sub -agreement with the VNA will be paid utilizing
funds from the IDPH grant.
RECOMMENDATION
It is recommended that the City Manager sign the attached subcontract with the Dubuque
County Board of Health and the agreement with the Dubuque Visiting Nurse Association
on behalf of the City of Dubuque.
MRC/cj
cc: Alvin Nash, Housing Services Manager
Susan Hubbard, VNA, Administrative Director
Kim Glaser, Healthy Homes Program Manage
2
SUBCONTRACT FOR HEALTHY HOMES AND CHILDHOOD LEAD POISONING
PREVENTION SERVICES
BETWEEN
DUBUQUE COUNTY BOARD OF HEALTH
AND
THE CITY OF DUBUQUE
WHEREAS, the Dubuque County Board of Health (County Board), as
Contractor, has entered into an Agreement (the Agreement) wit the Iowa Department of
Public Health to perform childhood lead poisoning prevention services as set forth in
the Agreement (Contract # 5883LP03), 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, THERFORE, 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 2014.
Richard Fairley, MD, Chair Michael C. Van Milligen
Dubuque County Board of Health City Manager
SUBCONTRACT
BETWEEN
THE CITY OF DUBUQUE, IOWA,
AND
THE DUBUQUE VISITING NURSE ASSOCIATION
FOR THE
HEALTHY HOMES AND CHILDHOOD LEAD POISONING PREVENTION PROGRAM
This Subcontract between the City of Dubuque, Iowa and The Visiting Nurse
Association is dated for reference purposes the 1st day of July, 2014.
Whereas, Dubuque County, Iowa (Contractor) has entered into Contract 5883LP03
with the Iowa Department of Public Health for Public Health (the Department) for the Healthy
Homes (HH) and Childhood Lead Poisoning Prevention Program (CLPPP) (the Contract), a
copy of which is attached hereto, pursuant to which Contractor will provide the work and
services described in the Contract in accordance with the Special Conditions therein, and the
General Conditions, a copy of which is attached hereto; and
Whereas, the City of Dubuque, Iowa (City) is the Contract Administrator of the
Contracts; and
Whereas, it is necessary for City to subcontract for certain work and services; and
Whereas, City now desires to enter into this Subcontract with the Visiting Nurse
Association (VNA) to provide the work and services described herein upon the terms and
conditions set forth herein.
NOW, THEREFORE, IT IS AGREED BY AND BETWEEN CITY AND VNA AS
FOLLOWS:
SECTION 1. WORK AND SERVICES. City and VNA agree to provide the following work
and services (the Work and Services):
1.1. City's Responsibilities. City agrees that it will provide the following services for the HH
& CLPPP:
(1) Submit reports/vouchers and other reporting requirements as required by the
Iowa Department of Public Health (IDPH), the Centers for Disease Control and
Prevention (CDC), and the Department of Housing and Urban Development (HUD).
(2) Provide for environmental investigations and environmental case management
for lead abatement\lead hazard reduction and healthy homes interventions 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 $4,000 for the performances of VNA's responsibilities as set forth herein.
(4) Oversee and direct medical case management and educational/outreach
activities through verbal and written direction.
1.2. VNA's Responsibilities. VNA agrees to provide the following services for HH &
CLPPP during the term of this Agreement for the agreed compensation:
(1) Provide written quarterly reports on lead and healthy homes activities utilizing
the Iowa Quarterly Report Narrative Outline.
(2) Provide electronic documentation of medical case management and related
activities into City's lead and healthy homes database systems, HHLPSS, and
of educational activities performed for each month by the 10th of the following
month.
(3) Blood Lead Testing.
(a) VNA shall assure that the State of Iowa Plan for Childhood Blood Lead
Testing (January 2004) is implemented within the CLPPP service area; that
medical providers conduct blood lead testing according to this plan; and may
also conduct blood lead testing.
(b) Shall provide a notification 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 pg/dL, regardless of whether the VNA did the
testing. The written notice shall include information regarding the meaning of
the 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.
(4) Medical Case Management:
(a) 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.
(b) Follow-up blood lead testing: Assure that providers in Dubuque County
that conduct blood lead testing provide follow-up blood lead testing for children
under the age of six years within the timelines listed below.
1. Confirmatory venous blood lead testing.
■ Capillary blood lead level of 15 - 19 pg/dL - within 4
weeks after report
• Capillary blood lead level of 20-44 pg/dL - within 1 week
after report
• Capillary blood lead level of 45 - 69 pg/dL - within 48
hours after the report
• Capillary blood lead level greater than or equal to 70
pg/dL — immediately
(5)
2. Follow-up testing after an elevated blood lead level for a child
who has not been chelated.
• Capillary or venous blood leads level of 10 - 14 pg/dL -
within 3 months. After two levels less than 10 pg/dL or
three levels less than 15 pg/dL, testing should follow the
routine testing schedule for high-risk children
• Venous blood lead level of 15 - 19 pg/dL - within 3
months
• Venous blood lead level of 20 - 44 pg/dL - within 4 to 6
weeks
• Venous blood lead level greater than or equal to 45 pg/dL
- immediately.
3. Follow-up testing for a child who has been chelated.
• At the end of chelation
• Depending on the blood lead level, 7 - 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:
(a) Shall assure that providers in Dubuque County provide/conduct medical
evaluations for children under the age of six years within the following
timelines:
1. Venous blood lead level of 20 - 44 pg/dL - refer within 48 hours
after the report so that the service is received within 5 days.
2. Venous blood lead level of 45 - 69 pg/dL - refer within 24 hours
after the report so that the service is received within 48 hours
3. Venous blood lead level greater than or equal to 70 pg/dL - refer
for emergency medical evaluation
(6) Home nursing or outreach visits:
(a) Provide home nursing or outreach visits for children under the age of six
years according to the following timelines:
1. Venous blood lead level of 15 - 19 pg/dL - within 4 weeks after
the report.
2. Venous blood lead level of 20 - 44 pg/dL - within 2 weeks after
the report.
3. Venous blood lead level of 45 - 69 pg/dL - within 1 week after the
report.
4. Venous blood lead level greater than or equal to 70 pg/dL -
within 2 days after the report
5. Conduct home visits as needed to families and residents in
order to provide medical case management, education and
prevention services in conjunction with HUD lead hazard
reduction and Healthy Homes activities.
(7) Chelation:
(a) Assure that children with two venous blood lead levels greater than or
equal to 45 pg/dL receive chelation.
(8) Nutrition evaluation:
(9)
(a) Assure that children under the age of six years with a venous blood lead
level greater than or equal to 15 pg/dL receive a nutrition evaluation
referral according to the following timelines:
1. Venous blood lead level of 15 - 19 pg/dL - refer within 4 weeks
after the report so that the service is received within 6 weeks
2. Venous blood lead level of 20 - 44 pg/dL - refer within 2 weeks
after the report so that the service is received within 4 weeks
3. Venous blood lead level of 45 - 69 pg/dL - refer within 1 week
after the report so that the service is received within 2 weeks
4. Venous blood lead level greater than or equal to 70 pg/dL - refer
within 2 days after the report so that the service is received with
1 week.
(b) Shall contact the IDPH 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 pg/dL.
Developmental Assessment:
(a) Shall assure that children under the age of six years with a venous
blood lead level greater than or equal to 20 pg/dL receive a
developmental assessment by referral to the AEA Early ACCESS
program according to the following timelines:
1. Venous blood lead level of 20 - 44 pg/dL - refer within 2 weeks
after the report
2. Venous blood lead level of 45 - 69 pg/dL - refer within 1 week
after the report
3. Venous blood lead level greater than or equal to 70 pg/dL - refer
within 2 days after the report.
(10) Care coordination. Shall provide medical care coordination as appropriate.
(11) Assist City with providing public education, lead/Healthy Homes coalition
development and activities, and outreach to the City of Dubuque residents
about childhood lead poisoning and Healthy Homes.
(12) Provide information about lead poisoning and available services to local
pediatric health care providers.
(13) Attend/participate in City -approved education and training opportunities to
further staff knowledge regarding lead and Healthy Homes.
(14) Participate with City in securing additional funding for childhood lead poisoning
prevention and healthy homes activities.
(15) 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.
(16) Assist the City with linkage to the Dubuque County Board of Health for CLPPP
planning and evaluation activities.
SECTION 2. CONTRACT POLICIES AND REQUIREMENTS. In providing the Work and
Services, VNA agrees to comply with the requirements in the Contract, including the Special
Conditions, and the General Conditions, to the extent applicable to the Work and Services
described in Section 1.
SECTION 3. ACCESS TO BOOKS AND RECORDS. VNA to provide access, upon
reasonable notice, for the purpose of audit and examination, to its documents, papers, and
records, to the extent such documents, papers, and records are related to the Work and
Services, to the Department, Contractor, City, or any of their duly authorized representatives.
SECTION 4. COSTS TO BE REIMBURSED. Attached hereto is a line item CLLLP
Performance Measure budget of specific costs to be reimbursed under this Subcontract or
other cost basis for determining the amount of the Subcontract. The Healthy Homes activities
will be invoiced to the City for VNA staff time plus benefits at 32%.
SECTION 5. INCORPORATION OF THE CONTRACT. VNA agrees that all of the
provisions of the Contract, including audit requirements, are incorporated herein by this
reference and VNA shall have all of the same requirements, obligations and conditions as
Contractor with respect to VNA's Work and Services.
SECTION 6. PERIOD OF PERFORMANCE. Unless terminated as provided herein, the
Period of Performance for the Work and Services shall be from the the 1st day of July 2012,
through the 30th day of June, 2013.
SECTION 7. TERMINATION. Either party may terminate this Subcontract for any reason,
with or without cause, upon ten (10) days written notice to the other party. In the event of
termination, City shall compensate VNA for its Work and Services rendered through the date
of termination.
SECTION 8 INDEMNIFICATION.
(1) VNA agrees to defend, indemnify, and hold Department, City and Contractor,
and their officers, and employees harmless from and against any and all claims of any
kind arising out of or related to VNA's negligence in the performance of the Work and
Services pursuant to this Subcontract.
(2) City agrees to defend, indemnify, and hold VNA and its officers, and
employees harmless from and against any and all claims of any kind arising out of or
related to City's negligence in the performance of the Work and Services pursuant to
this Subcontract.
SECTION 9. INSURANCE. VNA shall at its expense maintain insurance with the same
coverage which Contractor is required to maintain under Par. 13 of the General Conditions.
CITY OF DUBUQUE, IOWA VISITING NURSE ASSOCIATION
By:
rn.s n P(
Michael C. Van Milligen usan Hubbard
City Manager Administrative Director
City of Dubuque Insurance Requirements for Professional Services
Insurance Schedule C
1. shall furnish a signed Certificate of Insurance to the City of Dubuque, Iowa for the
coverage required in Exhibit I prior to commencing work and at the end of the project if the term of work is
longer than 60 days. Providers presenting annual certificates shall present a Certificate at the end of each
project with the final billing. Each Certificate shall be prepared on the most current ACORD form approved
by the Iowa Department of Insurance or an equivalent. Each certificate shall include a statement under
Description of Operations as to why issued. Eg: Project # or Lease of premises at or
construction of
2. All policies of insurance required hereunder shall be with a carrier authorized to do business in Iowa
and all carriers shall have a rating of A or better in the current A.M. Best's Rating Guide.
3. Each Certificate shall be furnished to the contracting department of the City of Dubuque.
4. 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.
5. Subcontractors and sub subcontractor performing work or service shall provide a Certificate of
Insurance in accord with Exhibit I.
6. All required endorsements to various policies shall be attached to Certificate of insurance.
7. Whenever a specific ISO form is listed, an equivalent form may be substituted subject to the
provider identifying and listing in writing all deviations and exclusions that differ from the ISO form.
8. Provider shall be required to carry the minimum coverage/limits, or greater if required by law or
other legal agreement, in Exhibit I.
9. Whenever an ISO form is referenced the current edition of the form must be used.
City of Dubuque Insurance Requirements for Professional Services
Insurance Schedule C (continued)
Exhibit I
A) COMMERCIAL GENERAL LIABILITY
General Aggregate Limit $2,000,000
Products -Completed Operations Aggregate Limit $1,000,000
Personal and Advertising Injury Limit $1,000,000
Each Occurrence $1,000,000
Fire Damage Limit (any one occurrence) $ 50,000
Medical Payments $ 5,000
a) Coverage shall be written on an occurrence, not claims made, form. All deviations from
the standard ISO commercial general liability form CG 0001, or Business owners form BP
0002, shall be clearly identified.
b) Include I50 endorsement form CG 25 04 "Designated Location(s) General Aggregate Limit"
or CG 25 03 "Designated Construction Project (s) General Aggregate Limit" as appropriate.
c) Include endorsement indicating that coverage is primary and non-contributory.
d) Include endorsement to preserve Governmental Immunity. (Sample attached).
e) Include an endorsement that deletes any fellow employee exclusion.
f) Include additional insured endorsement for:
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. Use ISO form CG 2026.
B) AUTOMOBILE LIABILITY $1,000,000 (Combined Single Limit)
C) WORKERS' COMPENSATION & EMPLOYERS LIABILITY
Statutory benefits covering all employees injured on the job by accident or disease as prescribed by
Iowa Code Chapter 85 as amended.
Coverage A
Coverage B
Statutory—State of Iowa
Employers Liability
Each Accident $100,000
Each Employee -Disease $100,000
Policy Limit -Disease $500,000
Policy shall include an endorsement providing a waiver of subrogation to the City of Dubuque.
Coverage B limits shall be greater if required by Umbrella Carrier.
D) UMBRELLA LIABILITY $1,000,000
Umbrella liability coverage must be at least following form with the underlying policies included
herein.
E) PROFESSIONAL LIABILITY $1,000,000
Page 2 of 3 Schedule C, Professional Services April, 2013.Doc
City of Dubuque Insurance Requirements for Professional Services
Preservation of Governmental Immunities Endorsement
1. Nonwaiver of Governmental Immunity. 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 Coverage. 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 Coverage. 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 Change in Policy. The above preservation of governmental immunities shall not otherwise change or
alter the coverage available under the policy.
SPECIMEN
Preservation of Governmental Immunities Endorsement
1. Nonwaiver of Governmental Immunity. 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 Coverage. 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 Coverage. 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 Change in Policy. The above preservation of governmental immunities shall not
otherwise change or alter the coverage available under the policy.
SPECIMEN
Iowa Department of Public Health
•IDPH Promoting and Protecting the Health of Iowans
Gerd W. Clabaugh, MPA
Interim Director
CONTRACT #: 5885LP03
PROJECT TITLE: Childhood Lead Poisoning
Prevention Program
FUNDING SOURCE OF IDPH:
FEDERAL: $0
STATE: $6,454
OTHER: $0
FEDERAL CATALOG #: NA
MATCH REQUIRED
YES NO X NA
FFATA REPORT REQUIRED:
YES NO N<1
Terry E. Branstad Kim Reynolds
Governor Lt. Governor
IOWA CODE CHAPTER 8F DESIGNATION:
This contract is covered by Iowa Code chapter 8F.
This contract is NOT covered by Iowa Code
Chapter 8F.
At the time of execution, this contract is NOT
covered by Iowa Code chapter 8F, but if the
Contractor executes additional contracts with the
Department, the aggregate of which exceed
$500,000, the contract may be covered.
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 January 1, 2013 Revised 1.10.13 as
posted on the Department's Web site under Funding Opportunities: www.idph.state.ia.us or as available by
contacting Kevin Officer at (515) 242-5902. The contractor specifies no changes have been made to the Special
Conditions or General Conditions.
PROJECT PERIOD: July 1, 2014 to June 30, 2015
CONTRACT PERIOD: July 1, 2014 to June 30, 2015
CONTRACT AMOUNT: $6,454
STATE OF IOWA DEPT. OF ADMINISTRATIVE
SERVICES VENDOR #:
00002128749
CONTRACTOR:
Dubuque County Board of Health
CONTRACT ADMINISTRATOR NAME:
Mary Rose Corrigan
AGENCY:
City of Dubuque Health Services Department
AGENCY ADDRESS:
City Hall Annex
1300 Main Street
Dubuque, IA, 52001
PHONE: 563-589-4181
FAX: 563-589-4299
The parties hereto have executed this contract on the day and year last specified below.
For and on behalf of the Department: For and on behalf of the Contractor:
By: By:
Ken Sharp, Director
Division of Acute Disease Prevention, Emergency
Response, & Environmental Health
Dr. Richard Fairley
Board of Health Chair
Lucas State Office Building, 321 E. 12th Street, Des Moines, IA 50319-0075 ■ 515-281-7689 • www.idph.state.ia.us
DEAF RELAY (Hearing or Speech Impaired) 711 or 1-800-735-2942
SPECIAL CONDITIONS FOR CONTRACT # 5885LP03
ARTICLE I – IDENTIFICATION OF PARTIES
[Insert] Board of Health (CONTRACTOR) has demonstrated through application to the DEPARTMENT
that it is prepared to provide the activities and authority outlined perlowaAdministrative Code (IAC) 641
Chapter 72. The CONTRACTOR has designated [INSERT DESIGNATED AGENCY] (hereinafter
referred to as the DESIGNATED AGENCY), to carry out the activities as required in IAC 641-72.2(3)
and described in this contract. The address of the DESIGNATED AGENCY is:
City Hall Annex
1300 Main Street
Dubuque, IA, 52001
ARTICLE II – IDENTIFICATION OF AUTHORIZED STATE OFFICIAL:
Ken Sharp, Director, Division of Acute Disease Prevention, Emergency Response, & Environmental
Health, 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 Kevin Officer, Community Health Consultant, at
kevin.officerc@idph.iowa.gov or 515-242-5902.
ARTICLE III – DESIGNATION OF AUTHORITY, CONTRACT ADMINISTRATOR, AND KEY
PERSONNEL
The CONTRACTOR, as listed on the contract face sheet, is responsible for financial and administrative
matters of this contract.
The CONTRACTOR has designated the Contract Administrator listed on the contract face sheet the
authority to manage the contract, to assure compliance with all conditions, and to negotiate matters
concerning this project. The Contract Administrator will receive key communications from the
DEPARTMENT and will be responsible for keeping the CONTRACTOR and all authorized agencies
informed.
In addition to the CONTRACTOR and the Contract Administrator, additional individuals(s) as listed
below shall be considered key personnel and may sign claims.
Table A:
Name
Title
Michael C. Van Milligen
Agency Director
Mary Rose Corrigan
Program Administrator
Ken TeKippe
Finance Manager
Laura Hankes
Data Entry Clerk
Michelle Zurcher
Nurse
Mary Rose Corrigan
Certified Elevated Blood Lead (EBL) Inspector/Risk Assessor
ARTICLE IV – STATEMENT OF CONTRACT PURPOSE
The purpose of this contract is to provide funds for the CONTRACTOR to ensure that childhood lead
poisoning prevention activities are conducted as specified in this contract and in compliance IAC 641—
Chapter 72.
ARTICLE V - DEFINITIONS
DEFINITIONS
"Blood lead testing" means taking a capillary or venous sample of blood and sending it to a laboratory to
determine the level of lead in the blood.
"Capillary" means a blood sample taken from the fmger 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.
"Certified elevated blood lead (EBL) 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 (EBL) inspector/risk assessor" means a person who has met the
requirements of 641 70.5035) 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.
"Community partnership" means a collaborative relationship between entities to address healthy homes
issues and lead poisoning prevention in the CLPPP service area.
"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, documenting all 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 HHLPSS database, and providing all
HHLPSS reports required by this contract.
`Developmental testing" means testing done by the local Early Access Program or Area Education
Agency to determine whether a child is developmentally delayed.
"Education and outreach "means seeking out and providing information regarding childhood lead
poisoning and healthy homes 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 (EBL) child" means any child who has had one venous blood lead level greater than
or equal to 20 micrograms per deciliter (µg/dL) or at least two venous blood lead levels of 15 to 19
µg/dL.
`Elevated blood lead (EBL) 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 dwelling or child -
occupied facility being inspected and to the parents of the elevated blood lead (EBL) child.
`Elevated blood lead (EBL) 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 perform 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 µg/dL.
"HHLPSS" means the Healthy Homes and Lead Poisoning Surveillance System web based case
management program.
"Healthy homes planning" means assessing housing issues other than lead in the community, developing
a network of service providers that could assist with housing issues other than lead, and participating in a
state or local healthy homes and lead poisoning prevention program advisory group or coalition.
"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.
"Laboratory" means a laboratory certified to perform either waived or non -waived blood lead analysis
according to the federal Clinical Laboratory Improvement Act of 1988 (CLIA).
"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.
"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 µg/dL 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 healthy homes and 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.
"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.
"Venous" means a blood sample taken from a vein in the arm for lead analysis.
ARTICLE VI — DESCRIPTION OF WORK AND SERVICES
The CONTRACTOR shall ensure that childhood lead poisoning prevention seryices are conducted as
specified in this contract.
CLPPP SERVICE AREA
The CLPPP service area is Dubuque County.
REOI TIRED SERVICES
The CONTRACTOR shall ensure that the DESIGNATED AGENCY implements all of the required
reimbursable services as described below within the CLPPP service area. The required services are
medical case management (home nursing visits, referrals for nutrition counseling, and referrals for
developmental testing), environmental case management inspections for lead -poisoned children,
contacting property owners to determine if lead hazard remediation is completed, conducting inspections
to determine if lead hazard remediation is complete, and performing clearance testing to assure that lead
hazard remediation has been completed in a safe manner, and data management. The CONTRACTOR
shall ensure that the DESIGNATED AGENCY develops written protocols to describe how each of these
services will be provided. Templates provided by the DEPARTMENT may be used to develop these
protocols.
OPTIONAL SERVICES
Optional reimbursable services include conducting blood lead testing, contacting families and health care
providers, education and outreach, community partnerships, healthy homes planning, x-ray fluorescence
analyzer source replacement, initial elevated blood lead (EBL) inspector/risk assessor certification, and
refresher elevated blood lead (EBL) inspector/risk assessor certification. The DESIGNATED AGENCY
shall determine which optional services will be carried out in the CLPPP service area.
BLOOD LEAD TESTING
The CONTRACTOR shall ensure that the DESIGNATED AGENCY:
• Implements the State of Iowa Plan for Childhood Blood Lead Testing (January 2004) within the
CLPPP service area.
• Conducts blood lead testing or ensures that medical providers conduct blood lead testing
according to this plan.
• Provides a written notice of the results of blood lead testing to the caregivers of all children tested
by the DESIGNATED AGENCY. 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.
• Provides 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 µg/dL, regardless of
who did the testing. The written notice shall include information regarding the meaning of the
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. This may be waived if the CLPPP collaborates with
health care providers that provide this information to the parents. The CONTRACTOR shall
ensure that the DESIGNATED AGENCY notifies the DEPARTMENT of such agreements in
writing.
ATA MANAGEMENT
The CONTRACTOR shall ensure that the DESIGNATED AGENCY:
• Conducts data management as specified in this contract.
• Documents all case management actions taken by the DESIGNATED AGENCY 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 HHLPSS database and shall
ensure that all CLPPP subcontractors also document all case management actions that they take in
HHLPSS.
• Provides all HHLPSS reports by the deadlines given in this contract. The DEPARTMENT will
periodically review the DESIGNATED AGENCY HHLPSS database for errors and notify the
DESIGNATED AGENCY of errors that must be corrected. Corrects the errors by the date
specified in the notification and shall implement quality control measures to prevent data entry
errors.
ENVIRONMENTAL CASE MANAGEMENT
The CONTRACTOR shall ensure that the DESIGNATED AGENCY:
• Maintains 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 or DESIGNATED AGENCY and the certified individuals shall comply with the
provisions of Iowa Administrative Code 641 70.6(3).
• Enrolls as a Medicaid provider for EBL inspection services, recovers reimbursement from
Medicaid for EBL inspections, and uses the reimbursement as program income.
• Conducts 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 µg/dL or at least two venous blood
lead levels of 15 to 19 µg/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 µg/dL or three blood lead levels less than 15
µg/dL. EBL inspections shall be conducted within the following times:
Si, Two venous blood lead levels of 15 to 19 µg/dL — within 4 weeks after the report.
Si, Venous blood lead level of 20 to 44 µg/dL — within 2 weeks after the report.
Si, Venous blood lead level of 45 to 69 µg/dL — within 1 week after the report.
Si, Venous blood lead level greater than or equal to 70 µg/dL — within 2 days after the
report.
• Documents in HHLPSS the reason why the DESIGNATED AGENCY was unable to complete
any inspection required by this contract.
• Contacts 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.
• Contacts the current owners of all dwellings where lead hazards were identified, but lead hazard
remediation has not been completed, at least once each year until lead hazard remediation is
completed.
• Continues 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.
• Does not close an address associated with a lead -poisoned child where lead hazards have been
identified unless the lead hazard remediation has been completed or written permission has been
obtained in advance from the DEPARTMENT to close the address even though lead hazard
remediation has not been completed.
• To the extent possible, assists families who have lead -poisoned children in locating resources for
lead hazard remediation and/or alternative housing.
• Conducts clearance testing according to Iowa Administrative Code Chapter 641 70, Lead
Professional Certification, before verifying that lead hazard remediation has been completed in a
home associated with a lead -poisoned child.
The CONTRACTOR must adopt and enforce a local code that requires hazards to be repaired in the
homes of elevated blood lead (EBL) children. A model code is available at Iowa Administrative Code
641 Chapter 68. CONTRACTORS may adopt this model code by reference.
Local regulations must be as protective as Iowa Administrative Code 641 Chapter 68. Local regulations
that were previously adopted must be updated to reflect safe dust lead levels and other items that have
changed since the local regulations were adopted.
MEDICAL CASE MANAGEMENT
The CONTRACTOR shall ensure that the DESIGNATED AGENCY:
• Conducts medical case management as specified in this contract.
• Is enrolled as a Medicaid provider for services that can be reimbursed by Medicaid, recovers
reimbursement from Medicaid for medical case management services, and uses the
reimbursement as program income.
Follow -un blood lead testing
The CONTRACTOR shall ensure that the DESIGNATED AGENCY:
• Assures that providers in the CLPPP service area 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
DESIGNATED AGENCY may also provide this follow-up blood lead testing.
Confirmatory venous blood lead testing
➢ Capillary blood lead level of 15 to 19 µg/dL — within 4 weeks after the report.
➢ Capillary blood lead level of 20 to 44 µg/dL — within 1 week after the report.
➢ Capillary blood lead level of 45 to 69 µg/dL — within 48 hours after the report.
➢ Capillary blood lead level greater than or equal to 70 µg/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 µg/dL — within 3 months. After two
levels less than 10 µg/dL or three levels less than 15 µg/dL, testing should follow the
routine testing schedule for high-risk children.
Si, Venous blood lead level of 15 to 19 µg/dL — within 3 months.
Si, Venous blood lead level of 20 to 44 µg/dL — within 4 to 6 weeks.
Si- Venous blood lead level greater than or equal to 45 µg/dL — immediately.
Follow-up testing 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 ensure that the DESIGNATED AGENCY:
• Assures that providers in the CLPPP conduct medical evaluations for children under the age of
six years within the following timelines:
Si, Venous blood lead level of 20 to 44 µg/dL — Refer within 48 hours after the report so that
the service is received within 5 days.
Si, Venous blood lead level of 45 to 69 µg/dL — Refer within 24 hours after the report so that
the service is received within 48 hours.
Si, Venous blood lead level greater than or equal to 70 µg/dL — Refer for emergency medical
evaluation.
Home nursing or outreach visits
The CONTRACTOR shall ensure that the DESIGNATED AGENCY provides home nursing or outreach
visits for children under the age of six years according to the following timelines:
Si, Venous blood lead level of 15 to 19 µg/dL — within 4 weeks after the report.
Si, Venous blood lead level of 20 to 44 µg/dL — within 2 weeks after the report
Si, Venous blood lead level of 45 to 69 µg/dL — within 1 week after the report
Si, Venous blood lead level greater than or equal to 70 µg/dL — within 2 days after the
report.
Chelation
The CONTRACTOR shall ensure that the DESIGNATED AGENCY
• Assures that children with two venous blood lead levels greater than or equal to 45 µg/dL receive
chelation.
Nutrition Evaluation
The CONTRACTOR shall ensure that the DESIGNATED AGENCY:
• Assures that children under the age of six years with a venous blood lead level greater than or
equal to 15 µg/dL receive a nutrition evaluation according to the following timelines:
Si, Venous blood lead level of 15 to 19 µg/dL — Refer within 4 weeks after the report so that
the service is received within 6 weeks.
Si, Venous blood lead level of 20 to 44 µg/dL — Refer within 2 weeks after the report so that
the service is received within 4 weeks.
Si, Venous blood lead level of 45 to 69 µg/dL — Refer within 1 week after the report so that
the service is received within 2 weeks.
Si, Venous blood lead level greater than or equal to 70 µg/dL — Refer within 2 days after the
report so that the service is received with 1 week.
• Contacts the DEPARTMENT for assistance if access to a dietitian cannot be assured for children
under the age of six years with a venous blood lead level greater than or equal to 15 µg/dL.
j)evelonmental Assessment
The CONTRACTOR shall ensure that the DESIGNATED AGENCY:
• Assures that children under the age of six years with a venous blood lead level greater than or
equal to 20 µg/dL receive a developmental assessment according to the following timelines:
Si, Venous blood lead level of 20 to 44 µg/dL — Refer within 2 weeks after the report.
Si, Venous blood lead level of 45 to 69 µg/dL — Refer within 1 week after the report
Si, Venous blood lead level greater than or equal to 70 µg/dL — Refer within 2 days after the
report.
Care Coordination
The CONTRACTOR shall ensure that the DESIGNATED AGENCY provides care coordination or refers
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 µg/dL or three consecutive blood
lead levels less than 15 µg/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 µg/dL immediately after a single capillary blood lead level greater than or equal
to 15 µg/dL.
3. A child has reached the age of six years and has a blood lead level less than 20 µg/dL.
4. A child has moved out of the CLPPP service area. The CONTRACTOR shall ensure that the
DESIGNATED AGENCY immediately notifies IDPH.
CHILDREN OVER THE AGE OF SIX YEARS
The CONTRACTOR shall ensure that the DESIGNATED AGENCY contacts 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 µg/dL.
ARTICLE VII—REPORTS
The CONTRACTOR shall ensure that the DESIGNATED AGENCY prepares and submits the following
reports to the DEPARTMENT on forms and/or in the format approved by the DEPARTMENT:
Report Number Date Due
Claim Voucher 1 electronic Within 45 days of month of expenditure
Expenditure Report 1 electronic Within 45 days of month of expenditure
HHLPSS Documentation to 1 electronic Within 45 days of month of expenditure
Support Expenditure Report
Quarterly Narrative Report 1 electronic 10-25-2014
1-27-2015
4-25-2015
7-25-2015
Claim vouchers and expenditure reports shall be filed via IowaGrants.gov.
HHLPSS documentation and quarterly narrative reports to support the expenditure report shall be
uploaded to IowaGrants.gov.
ARTICLE VIII-- BUDGET
1. The total approved budget for this contract period is detailed in Exhibit 1. All services except for
initial EBL inspector certification and EBL inspector refresher training will be reimbursed at a
flat fee as specified on Exhibit 1 up to the amount of the contract.
2. Initial EBL inspector certification and EBL inspector refresher training will be reimbursed at
actual cost up to the maximum amount shown on Exhibit 1. The Department will not reimburse
travel amounts in excess of limits established by Iowa Department of Administrative Services:
Instate maximum allowable amounts for food is $8.00/breakfast; $12.00/lunch; and
$23.00/dinner; lodging maximum of $83.00, plus taxes per night; and mileage maximum of
$0.39 per mile.
3. The CONTRACTOR or DESIGNATED AGENCY may change the number of any "required
service" 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.
4. The CONTRACTOR or DESIGNATED AGENCY may change the total amount of funds that the
DEPARTMENT will reimburse under this contract for "optional services" or "required services"
only after filing a written request for the revision and receiving written approval for this change.
5. The CONTRACTOR or DESIGNATED AGENCY may change the number of any "optional
services" deliverable that the DEPARTMENT will reimburse under this contract without
permission from the DEPARTMENT providing that the total amount expended for optional
services does not exceed the amount provided in the contract.
ARTICLE IX — PAYMENTS
1. Warrants will be made payable to the CONTRACTOR and mailed to the Contract Administrator
at the DESIGNATED AGENCY address. Warrants may be sent to an alternate address if
requested in writing from the CONTRACTOR.
2. Payments shall be made to the CONTRACTOR based on the expenditure reports and claim
vouchers submitted to the DEPARTMENT by the DESIGNATED AGENCY.
3. Final payment may be withheld until all contractually required reports have been received and
accepted by the DEPARTMENT. At the end of the contract period, unobligated contract amount
funds shall revert to the DEPARTMENT.
ARTICLE X — ADDITIONAL CONDITIONS
1. Funds may not be spent for indirect costs, chelation or other medical treatment of lead poisoning,
or lead hazard remediation. Funds may not be spent for blood lead analyses that could be
reimbursed by Medicaid.
2. On January 1, 2015, April 1, 2015, and June 1, 2015, the DEPARTMENT may amend the
contract to revert funds that are estimated to be unused to the DEPARTMENT and to reallocate
the funds to contractors with demonstrated special needs for healthy homes and childhood lead
poisoning prevention services.
3. Payments may be withheld if the DESIGNATED AGENCY or personnel employed by the
DESIGNATED AGENCY are not in compliance with Iowa Administrative Code Chapter 641
70, Lead Professional Certification.
4. The CONTRACTOR and/or DESIGNATED AGENCY must check Internet e-mail at least once
each week for lead poisoning prevention updates sent out by the DEPARTMENT.
5. 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
encouraged 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.
6. The CONTRACTOR shall comply with Section 5 of the General Conditions for all subcontracts.
7. As a condition of the contract, the CONTRACTOR shall ensure that the DESIGNATED
AGENCY provides linkage with the local board of health in each county where services are
provided. The DESIGNATED AGENCY will ensure 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.
8. All work plan revisions must be approved by the DEPARTMENT prior to implementation.
9. Authorization - Each signatory to this contract or subsequent contract amendments represents and
warrants to the other parties that:
a. The signatory has the right, power, and authority to enter into this agreement and to bind the
party represented by the signatory to this agreement
b. The party has the right, power, and authority to perform its obligations under the agreement;
and
c. The party has taken all requisite action (corporate, statutory, or otherwise) to approve
execution, delivery, and performance of this agreement and this agreement constitutes a legal,
valid, and binding obligation upon itself in accordance with its terms.
CONTRACTOR: Dubuque County BOH
EXHIBIT 1 -- EXPENDITURE REPORT FOR THE MONTH OF
CONTRACT: 5885LP03
CONTRACT PERIOD: July 1, 2014 to June 30, 2015 Vendor Code: 00002128749
Required Services - Unit Cost Reimbursement
Line Description
Budgeted Rate (A)
Budgeted
Number
Budgeted
Total (B)
Number
Completed for
Month (C)
Reimbursement for
Month {A x C)
Number
Corrpleted to
Date
Reimbursement
to Date (D)
Balance (B -D)
Non -Medicaid Home Nursing Visits
80
3
$ 240
$
$
$
Referrals for Nutrition Counseling
10
3
$ 30
$
$
$
Referrals for Developmental Testing
10
2
$ 20
$
$
$
Non -Medicaid Initial Inspection Events
600
3
$ 1,800
$
$
$
EBL Investigation CONTC Events
10
55
$ 550
$
$
$
Corrpleted Lead Hazard Remediations
10
2
$ 20
$
$
$
EBL Investigation INSAB, INSAI, INSAE Events
80
7
$ 560
$
$
$
EBL Investigation Properties Passing Clearance
Testing
300
1
$ 300
$
$
$
Narrative Quarterly Report Submitted on Time
25
4
$ 100
$
$
$
Total Required Services
$ 3,620
Optional Services - Unit Cost Reimbursement
Line Description
Budgeted Rate (E)
Budgeted
Number
Budgeted
Total
Number
Completed for
Month (F)
Reimbursement for
Month (Ex F)
Number
Corrpleted to
Date
Reimbursement
to Date (G)
Balance (B -G)
XRF Source Replacement
2000
$
$
$
Non -Medicaid Blood Lead Sanple Collection
3
$
$
$
Child CONIC or ACTIO event
10
$
$
$
Education and Outreach, Community
Partnerships, and Healthy Homes Panning
Hours
50
$
$
$
Non -Medicaid Blood Lead Analysis
11
$
$
$
Optional Services - Cost Reimbursement Line
Description
Reimbursable
Expenses (H)
Reimbursement
to Date (H)
Balance (B-H)
Initial EBL Inspector Certification
Not to exceed
$3,000 per certification
1
EBL Inspector Refresher
Not to exceed
$1,500 per certification
Total Optional Services
$ 2,834
Total
$ 6,454
IDPH NOTE:
DOCUMENTATION OF PROGRAM INCOME
SIGNATURE:
DATE:
Amount for Month
Amount to Date
Program Income Earned
$
$
Program Income Received
$
$
Program Income Expended
$
$
SIGNATURE:
DATE: