Common use of Environmental Tobacco Smoke Clause in Contracts

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Attachment F- Revised AHS- 12/10/10 Appendix I – Required Forms Department of Vermont Health Access - I N V O I C E & RECONCILIATION - Date: NVRH : Start 7/1/14 18 Month Award $ : (Awardee to complete) Reconciliation: Current Month Cumulative Spending Spend to date: Award Balance Name / FTE% $ - $ - $ - $ - Name / FTE% $ - $ - $ - $ - Total Salary $ 54,000 $ - $ - $ 54,000 Fringe $ 18,900 $ - $ - $ 18,900 Travel $ 2,000 $ - $ - $ 2,000 Non-covered services $ 100,000 $ - $ - $ 100,000 Equipment Totals : $ 1,500 $ - $ - $ - $ - $ 176,400 $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ - $ 1,500- $ -- $ -- $ -- $ -- $ 176,400 Less: unspent Advances Net Invoice : $ - Instructions to report spending (above): The Awardee must prepare a detailed expenditures report identifying monthly spending and cumulative spending vs budget. Please use this Excel spreadsheet. To begin, please first complete the "Spend trend" tab. "Cumulative Spend to Date" and "Unspent Award Balance" values on this " Invoice & Reconciliation" sheet will auto-calculate. Then, please copy the current month spending from the Spend Trend Tab to this schedule in column "E" titled: "Current Month Spending" Please deduct any unspent advances from the current month to calculate the new invoice value Request for Approval to Subcontract Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Program Manager: Signature: Phone Number: Business Office Review Comments:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Attachment F- Revised AHS- 12/10/10 Appendix APPENDIX I – Required Forms Department of Vermont Health Access REQUIRED FORMS DEPARTMENT OF VERMONT HEALTH ACCESS - I N V O I C E & RECONCILIATION - Date: NVRH : Start 7/1/14 18 Month Award $ : (Awardee to complete) Reconciliation: 28 Month Current Month Cumulative Award Healthfirst : Award $ : Spending Spend to datedate Balance Name: Award Balance Name / FTE% Exec Director $ 215,000 $ - $ - $ 215,000 Part time Administrative Asst $ 65,000 $ - $ - Name / FTE% $ 65,000 Fringes $ - $ - $ - $ - Total Salary & Fringes $ 54,000 280,000 $ - $ - $ 54,000 Fringe 280,000 Consulting: Clinical Lead $ 18,900 55,000 $ - $ - $ 18,900 Travel 55,000 Legal services, HR, other $ 2,000 40,000 $ - $ - $ 2,000 Non40,000 Bi-covered services annual meeting $ 100,000 9,000 $ - $ - $ 100,000 Equipment Totals : 9,000 Computers, communication, IT support $ 1,500 7,000 $ - $ - $ - 7,000 Meetings and travel $ - $ 176,400 $ - $ $ - $ $ - $ $ - $ $ - $ 9,000 $ - $ - $ 1,500- 9,000 Total : $ -- 400,000 $ -- - $ -- - $ -- $ 176,400 400,000 Less: unspent Advances Net Invoice : $ - Instructions to report spending (above): The Awardee must prepare a detailed expenditures report identifying monthly spending and cumulative spending vs budget. Please use this Excel spreadsheet. To begin, please first complete the "Spend trend" tab. "Cumulative Spend to Date" and "Unspent Award Balance" values on this " Invoice & Reconciliation" sheet will auto-calculate. Then, please copy the current month spending from the Spend Trend Tab to this schedule in column "E" titled: "Current Month Spending" ". Please deduct any unspent advances from the current month to calculate the new invoice value Request for Approval to Subcontract Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Program Manager: Signature: Phone Number: Business Office Review Comments:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Attachment F- Revised AHS- 12/10/10 Appendix APPENDIX I – Required Forms Department of Vermont Health Access REQUIRED FORMS DEPARTMENT OF VERMONT HEALTH ACCESS - I N V O I C E & RECONCILIATION - Date: NVRH : Bi-State Primary Care Start 7/1/14 18 27 Month Award $ : (Awardee to complete) Current Month Spending Reconciliation: Current Month Cumulative Spending Spend to date: Award Balance Xxxxx Xxxxxxxxx 76,125.00 - 76,125.00 Name / FTE% $ 50,000.00 - $ 50,000.00 Name 37,750.00 - $ - $ - Name / FTE% $ - $ - $ - $ - 37,750.00 Total Salary $ 54,000 $ 163,875.00 - $ 163,875.00 Fringe - $ 54,000 Fringe $ 18,900 $ - $ - $ 18,900 Travel $ 2,000 $ - $ - $ 2,000 Non-covered services $ 100,000 $ - $ Meetings - $ 100,000 Equipment - - Professional Services - - - Facility Costs - - - Indirect - - - Totals : $ 1,500 $ 163,875.00 - $ - $ - $ - $ 176,400 $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ - $ 1,500- $ -- $ -- $ -- $ -- $ 176,400 163,875.00 Less: unspent Advances Net Invoice : $ - Instructions to report spending (above): The Awardee must prepare a detailed expenditures report identifying monthly spending and cumulative spending vs budget. Please use this Excel spreadsheet. To begin, please first complete the "Spend trend" tab. "Cumulative Spend to Date" and "Unspent Award Balance" values on this " Invoice & Reconciliation" sheet will auto-calculate. Then, please copy the current month spending from the Spend Trend Tab to this schedule in column "E" titled: "Current Month Spending" Please deduct any unspent advances from the current month to calculate the new invoice value Request for Approval to Subcontract Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Program Manager: Signature: Phone Number: Business Office Review Comments:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Attachment F- Revised AHS- 12/10/10 Appendix I – Required Forms Department of Vermont Health Access - I N V O I C E & RECONCILIATION - Date: NVRH : Start 7/1/14 18 Month Award $ : (Awardee to complete) Reconciliation: 24 Month Current Month Cumulative Award RAVNAH : Award $ : Spending Spend to date: Award Balance Name / FTE% MA Health Coach $ 117,333 $ - $ - $ 117,333 Lexi Xxxxxxxxx $ 72,800 $ - $ - $ 72,800 Team based care $ 52,000 $ - $ - $ 52,000 Total Salary $ 242,133 $ - $ - $ 242,133 Fringe $ - $ - $ - $ - Name / FTE% Conference Travel $ - $ - $ - $ - Total Salary $ 54,000 $ - $ - $ 54,000 Fringe $ 18,900 $ - $ - $ 18,900 Travel $ 2,000 $ - $ - $ 2,000 Non-covered services $ 100,000 $ - $ - $ 100,000 Equipment Totals : $ 1,500 Supplies $ - $ - $ - $ - $ 176,400 $ - $ $ - $ $ - $ $ - $ $ - $ 242,133 $ - $ - $ 1,500- $ -- $ -- $ -- $ -- $ 176,400 242,133 Less: unspent Advances Net Invoice : $ - Instructions to report spending (above): The Awardee must prepare a detailed expenditures report identifying monthly spending and cumulative spending vs budget. Please use this Excel spreadsheet. To begin, please first complete the "Spend trend" tab. "Cumulative Spend to Date" and "Unspent Award Balance" values on this " Invoice & Reconciliation" sheet will auto-calculate. Then, please copy the current month spending from the Spend Trend Tab to this schedule in column "E" titled: "Current Month Spending" Please deduct any unspent advances from the current month to calculate the new invoice value Request for Approval to Subcontract Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Program Manager: Signature: Phone Number: Business Office Review Comments:Advances

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Attachment F- Revised AHS- 12/10/10 Appendix APPENDIX I – Required Forms Department of Vermont Health Access REQUIRED FORMS DEPARTMENT OF VERMONT HEALTH ACCESS - I N V O I C E & RECONCILIATION - Date: NVRH : Start 7/1/14 18 Reconciliation: 24 Month Cumulative Award White River Family Practice Award $ : (Awardee to complete) Reconciliation: Current Month Cumulative Spending Spend to date: Award Balance Name / FTE% Xxxx Xxxxx $ 99,008 $ - $ - 99,008 Lexi Xxxxxxxxx $ 20,000 $ - $ - Name / FTE% 20,000 Xxxx Xxxxxxxx $ 23,100 $ - $ 23,100 $ - $ - $ - Total Salary $ 54,000 142,108 $ - $ - $ 54,000 142,108 Fringe $ 18,900 17,168 $ - $ - $ 18,900 17,168 Conference Travel $ 2,000 3,000 $ - $ - 3,000 Supplies $ 2,000 Non-covered services $ 100,000 500 $ - $ - 500 Equipment $ 100,000 Equipment Totals : $ 1,500 36,818 $ - $ - 36,818 Xxxx Xxxxxxx, MD $ 115,200 $ - $ - 115,200 Symquest $ 176,400 7,500 $ - $ 7,500 Cert Diabetes Educator $ 270 $ - $ 270 Dev't of Health Coach Curriculum $ 7,500 $ - $ 7,500 Indirect $ 33,006 $ - $ 33,006 Total : $ 363,070 $ - $ $ - $ - $ 1,500- $ -- $ -- $ -- $ -- $ 176,400 Less: unspent Advances Net Invoice : $ - 363,070 Instructions to report spending (above): The Awardee must prepare a detailed expenditures report identifying monthly spending and cumulative spending vs budget, and also report cumulative advances of grant funds. Please use this Excel spreadsheet. To begin, please first complete the "Spend trend" tab. "Cumulative Spend to Date" and "Unspent Award Balance" values on this " Invoice & Reconciliation" sheet will auto-calculate. Then, please copy the current month spending from the Spend Trend Tab to this schedule in column "E" titled: "Current Month Spending" Please deduct any unspent advances from the current month to calculate the new invoice value Request for Approval to Subcontract Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Program Manager: Signature: Phone Number: Business Office Review Comments:tab 1st.

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Attachment F- Revised AHS- 12/10/10 Appendix APPENDIX I – Required Forms Department of Vermont Health Access REQUIRED FORMS DEPARTMENT OF VERMONT HEALTH ACCESS - I N V O I C E & RECONCILIATION - Date: NVRH : Start 7/1/14 18 Month Award $ : (Awardee to complete) Reconciliation: Current Month Cumulative Spending Spend to date: Award Balance Name / FTE% $ - $ - $ - $ - Name / FTE% $ - $ - $ - $ - Total Salary $ 54,000 $ - $ - $ 54,000 Fringe $ 18,900 $ - $ - $ 18,900 Travel $ 2,000 $ - $ - $ 2,000 Non-covered services $ 100,000 $ - $ - $ 100,000 Equipment Totals : $ 1,500 $ - $ - $ - $ - $ 176,400 $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ - $ 1,500- $ -- $ -- $ -- $ -- $ 176,400 Less: unspent Advances Net Invoice : $ - Instructions to report spending (above): The Awardee must prepare a detailed expenditures report identifying monthly spending and cumulative spending vs budget. Please use this Excel spreadsheet. To begin, please first complete the "Spend trend" tab. "Cumulative Spend to Date" and "Unspent Award Balance" values on this " Invoice & Reconciliation" sheet will auto-calculate. Then, please copy the current month spending from the Spend Trend Tab to this schedule in column "E" titled: "Current Month Spending" Please deduct any unspent advances from the current month to calculate the new invoice value Request for Approval to Subcontract Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Program Manager: Signature: Phone Number: Business Office Review Comments:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Attachment F- Revised AHS- 12/10/10 Appendix I – Required Forms AHS -4-06-09 CHANGE # 2 AMENDMENT It is agreed by and between the State of Vermont, Department of Vermont Health Access - I N V O I C E & RECONCILIATION - DateCorrections (hereafter called “State”) and Public Communication Services (PCS) of Los Angeles, CA (hereafter called “Contractor”) that contract #10314 dated October 1, 2006 between said State and Contractor is hereby amended as follows: NVRH : Start 7/1/14 18 Month Award $ : (Awardee To change Page 1, 4. Contract Term, from end on 09/30/2008 to complete) Reconciliation: Current Month Cumulative Spending Spend to date: Award Balance Name / FTE% $ - $ - $ - $ - Name / FTE% $ - $ - $ - $ - Total Salary $ 54,000 $ - $ - $ 54,000 Fringe $ 18,900 $ - $ - $ 18,900 Travel $ 2,000 $ - $ - $ 2,000 Non-covered end on 09/30/2009. Additionally, it is hereby agreed and understood that this contract has no minimum amount. The Contractors’ services $ 100,000 $ - $ - $ 100,000 Equipment Totals : $ 1,500 $ - $ - $ - $ - $ 176,400 $ - $ $ - $ $ - $ $ - $ $ - $ $ - $ - $ 1,500- $ -- $ -- $ -- $ -- $ 176,400 Less: unspent Advances Net Invoice : $ - Instructions to report spending (above): The Awardee must prepare a detailed expenditures report identifying monthly spending and cumulative spending vs budget. Please use this Excel spreadsheetwill be required on an “as needed” basis. To beginreplace existing Attachment C with new Attachment C, please first complete the "Spend trend" tabrevised May 23, 2008. "Cumulative Spend To replace existing Attachment F with new Attachment F, revised April 11, 2008. To replace page 1, number 7 to Date" and "Unspent Award Balance" values on this " Invoice & Reconciliation" sheet will auto-calculate. Thenread, please copy the current month spending from the Spend Trend Tab to this schedule “This contract may be cancelled by either party by giving written notice at least 180 days in column "E" titled: "Current Month Spending" Please deduct any unspent advances from the current month to calculate the new invoice value Request for Approval to Subcontract Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Program Manager: Signature: Phone Number: Business Office Review Comments:advance.”

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Attachment F- Revised AHS- 12/10/10 Appendix APPENDIX I – Required Forms Department of Vermont Health Access REQUIRED FORMS DEPARTMENT OF VERMONT HEALTH ACCESS - I N V O I C E & RECONCILIATION - Date: NVRH : 7/1/14 Start 7/1/14 18 Month Award $ : (Awardee to complete) Reconciliation: 26 Month Current Month Cumulative Award VMS: Award $ : Spending Spend to date: Award Balance Name / FTE% Xxxxx Xxxxxx $ 56,333 $ - $ - $ - 56,333 Xxxxxxx Xxxxx $ - Name / FTE% 12,462 $ - $ - $ - 12,462 Xxxxxxxxx Xxxxxxx $ - Total Salary $ 54,000 12,462 $ - $ - $ 54,000 Fringe 12,462 Xxx Xxxxxxxxx $ 18,900 7,000 $ - $ - $ 18,900 Travel 7,000 Total Salary & Fringes $ 2,000 88,257 $ - $ - $ 2,000 Non-covered services 88,257 Travel $ 100,000 3,390 $ - $ - $ 100,000 Equipment Totals : 3,390 Learning Sessions Conference $ 1,500 8,100 $ - $ - $ - 8,100 Faculty meetings $ - $ 176,400 $ - $ $ - $ $ - $ $ - $ $ - $ 1,440 $ - $ - $ 1,500- 1,440 CME Registration $ -- 2,500 $ -- - $ -- - $ -- 2,500 CME certificates $ 176,400 900 $ - $ - $ 900 Website $ 4,000 $ - $ - $ 4,000 Conference Call service $ 3,000 $ - $ - $ 3,000 Printing/Supplies $ 6,000 $ - $ - $ 6,000 Consulting - UVM Dept of Pathology $ 59,076 $ - $ - $ 59,076 Consulting - Hospital Teams grant support $ 44,340 $ - $ - $ 44,340 Consulting - QI Consultant/Project Mgr $ 127,000 $ - $ - $ 127,000 Consulting - Hospital Medicine Champion $ 78,650 $ - $ - $ 78,650 Consulting - Clinical Content Expert $ 39,325 $ - $ - $ 39,325 Consulting - Choosing Wisely Champion $ 39,325 $ - $ - $ 39,325 Consulting - Community Hospital Medicine Expert $ 39,325 $ - $ - $ 39,325 Consulting - Plenary Session Speakers $ 3,000 $ - $ - $ 3,000 Consulting - Distance Learning Expert Presenters $ 1,200 $ - $ - $ 1,200 Totals : $ 548,828 $ - $ - $ 548,828 Less: unspent Advances Net Invoice : $ - Instructions to report spending (above): The Awardee must prepare a detailed expenditures report identifying monthly spending and cumulative spending vs budget. Please use this Excel spreadsheet. To begin, please first complete the "Spend trend" tab. "Cumulative Spend to Date" and "Unspent Award Balance" values on this " "Invoice & Reconciliation" sheet will auto-calculate. Then, please copy the current month spending from the Spend Trend Tab to this schedule in column "E" titled: "Current Month Spending" ". Please deduct any unspent advances from the current month to calculate the new invoice value Request for Approval to Subcontract Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Program Manager: Signature: Phone Number: Business Office Review Comments:

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Attachment F- Revised AHS- 12/10/10 Appendix I – Required Forms Department of Vermont Health Access - I N V O I C E & RECONCILIATION - Date: NVRH : Start 7/1/14 18 Month Award $ : (Awardee to complete) Reconciliation: 24 Month Current Month Cumulative Award RAVNAH : Award $ : Spending Spend to date: Award Balance Name / FTE% MA Health Coach $ 117,333 $ - $ - $ 117,333 Lexi Xxxxxxxxx $ 72,800 $ - $ - $ 72,800 Team based care $ 52,000 $ - $ - $ 52,000 Total Salary $ 242,133 $ - $ - $ 242,133 Fringe $ - $ - $ - $ - Name / FTE% Conference Travel $ - $ - $ - $ - Total Salary $ 54,000 $ - $ - $ 54,000 Fringe $ 18,900 $ - $ - $ 18,900 Travel $ 2,000 $ - $ - $ 2,000 Non-covered services $ 100,000 $ - $ - $ 100,000 Equipment Totals : $ 1,500 Supplies $ - $ - $ - $ - $ 176,400 $ - $ $ - $ $ - $ $ - $ $ - $ 242,133 $ - $ - $ 1,500- $ -- $ -- $ -- $ -- $ 176,400 242,133 Less: unspent Advances Net Invoice : $ - Instructions to report spending (above): The Awardee must prepare a detailed expenditures report identifying monthly spending and cumulative spending vs budget. Please use this Excel spreadsheet. To begin, please first complete the "Spend trend" tab. "Cumulative Spend to Date" and "Unspent Award Balance" values on this " Invoice & Reconciliation" sheet will auto-calculate. Then, please copy the current month spending from the Spend Trend Tab to this schedule in column "E" titled: "Current Month Spending" Please deduct any unspent advances from the current month to calculate the new invoice value Request for Approval to Subcontract Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Program Manager: Signature: Phone Number: Business Office Review Comments:Advances

Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors. Attachment F- Revised AHS- 12/10/10 Appendix I – Required Forms Department of Vermont Health Access - I N V O I C E & RECONCILIATION - Date: NVRH : Start 7/1/14 18 Month Award $ : (Awardee to complete) Reconciliation: 28 Month Current Month Cumulative Award Healthfirst : Award $ : Spending Spend to datedate Balance Name: Award Balance Name / FTE% Exec Director $ 215,000 $ - $ - $ 215,000 Part time Administrative Asst $ 65,000 $ - $ - Name / FTE% $ 65,000 Fringes $ - $ - $ - $ - Total Salary & Fringes $ 54,000 280,000 $ - $ - $ 54,000 Fringe 280,000 Consulting: Clinical Lead $ 18,900 55,000 $ - $ - $ 18,900 Travel 55,000 Legal services, HR, other $ 2,000 40,000 $ - $ - $ 2,000 Non40,000 Bi-covered services annual meeting $ 100,000 9,000 $ - $ - $ 100,000 Equipment Totals : 9,000 Computers, communication, IT support $ 1,500 7,000 $ - $ - $ - 7,000 Meetings and travel $ - $ 176,400 $ - $ $ - $ $ - $ $ - $ $ - $ 9,000 $ - $ - $ 1,500- 9,000 Total : $ -- 400,000 $ -- - $ -- - $ -- $ 176,400 400,000 Less: unspent Advances Net Invoice : $ - Instructions to report spending (above): The Awardee must prepare a detailed expenditures report identifying monthly spending and cumulative spending vs budget. Please use this Excel spreadsheet. To begin, please first complete the "Spend trend" tab. "Cumulative Spend to Date" and "Unspent Award Balance" values on this " Invoice & Reconciliation" sheet will auto-calculate. Then, please copy the current month spending from the Spend Trend Tab to this schedule in column "E" titled: "Current Month Spending" ". Please deduct any unspent advances from the current month to calculate the new invoice value Request for Approval to Subcontract Date of Request: Original Grantee Name: Grantee #: Address: Phone Number: Contact Person: Agreement #: Signature: Subcontractor Name: Address: Phone Number: Contact Person: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? YES NO (Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Program Manager: Signature: Phone Number: Business Office Review Comments: