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. 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. State of Vermont Participating Addendum No. #29990 (“Participating Addendum”) Software Reseller Agreement Massachusetts Agreement No. ITS58 (“Master Agreement”) Purchase Order No. (Please refer to this assigned Purchase Order # on all correspondence, delivery documents and invoices.) This Purchase Order between the State of Vermont, CONTRACTING AGENCY (hereinafter the “State”) and CONTRACTOR NAME, with principal place of business in CITY, STATE, (hereinafter the “Contractor”) is an agreement entered into in accordance with the above-captioned Participating Addendum and Master Agreement. The parties acknowledge and agree that all terms and conditions of the Participating Addendum and Master Agreement (including respective amendments and attachments therewith) are hereby incorporated by reference and shall apply to this Purchase Order as if specifically appended hereto. This Purchase Order shall not in any way amend, conflict with, or supersede the Participating Agreement or Master Agreement, and any provision purporting to do so shall be void and have no effect. [Add the following sentence as applicable to AHS purchases:] This Purchase Order incorporates Attachments E and F attached to the Participating Addendum.

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. 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. State of Vermont Participating Addendum No. #29990 29992 (“Participating Addendum”) Software Reseller Agreement Massachusetts Agreement No. ITS58 (“Master Agreement”) Purchase Order No. (Please refer to this assigned Purchase Order # on all correspondence, delivery documents and invoices.) This Purchase Order between the State of Vermont, CONTRACTING AGENCY (hereinafter the “State”) and CONTRACTOR NAME, with principal place of business in CITY, STATE, (hereinafter the “Contractor”) is an agreement entered into in accordance with the above-captioned Participating Addendum and Master Agreement. The parties acknowledge and agree that all terms and conditions of the Participating Addendum and Master Agreement (including respective amendments and attachments therewith) are hereby incorporated by reference and shall apply to this Purchase Order as if specifically appended hereto. This Purchase Order shall not in any way amend, conflict with, or supersede the Participating Agreement or Master Agreement, and any provision purporting to do so shall be void and have no effect. [Add the following sentence as applicable to AHS purchases:] This Purchase Order incorporates Attachments E and F attached to the Participating Addendum.

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. 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. State of Vermont Participating Addendum No. #29990 (“Participating Addendum”) Software Reseller Agreement Massachusetts Agreement No. ITS58 (“Master Agreement”) Purchase Order No. (Please refer to this assigned Purchase Order CHANGE # on all correspondence, delivery documents 2 It is agreed by and invoices.) This Purchase Order between the State of Vermont, CONTRACTING AGENCY Department of Corrections (hereinafter the hereafter called “State”) and CONTRACTOR NAMEPublic Communication Services (PCS) of Los Angeles, with principal place of business in CITY, STATE, CA (hereinafter the hereafter called “Contractor”) that contract #10314 dated October 1, 2006 between said State and Contractor is an agreement entered into in accordance with the above-captioned Participating Addendum hereby amended as follows: To change Page 1, 4. Contract Term, from end on 09/30/2008 to end on 09/30/2009. Additionally, it is hereby agreed and Master Agreementunderstood that this contract has no minimum amount. The parties acknowledge and agree that all terms and conditions of the Participating Addendum and Master Agreement (including respective amendments and attachments therewith) are hereby incorporated Contractors’ services will be required on an “as needed” basis. To replace existing Attachment C with new Attachment C, revised May 23, 2008. To replace existing Attachment F with new Attachment F, revised April 11, 2008. To replace page 1, number 7 to read, “This contract may be cancelled by reference and shall apply to this Purchase Order as if specifically appended hereto. This Purchase Order shall not either party by giving written notice at least 180 days in any way amend, conflict with, or supersede the Participating Agreement or Master Agreement, and any provision purporting to do so shall be void and have no effect. [Add the following sentence as applicable to AHS purchases:] This Purchase Order incorporates Attachments E and F attached to the Participating Addendumadvance.”

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. 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. State of Vermont Participating Addendum No. #29990 29991 (“Participating Addendum”) Software Reseller Agreement Massachusetts Agreement No. ITS58 (“Master Agreement”) Purchase Order No. (Please refer to this assigned Purchase Order # on all correspondence, delivery documents and invoices.) This Purchase Order between the State of Vermont, CONTRACTING AGENCY (hereinafter the “State”) and CONTRACTOR NAME, with principal place of business in CITY, STATE, (hereinafter the “Contractor”) is an agreement entered into in accordance with the above-captioned Participating Addendum and Master Agreement. The parties acknowledge and agree that all terms and conditions of the Participating Addendum and Master Agreement (including respective amendments and attachments therewith) are hereby incorporated by reference and shall apply to this Purchase Order as if specifically appended hereto. This Purchase Order shall not in any way amend, conflict with, or supersede the Participating Agreement or Master Agreement, and any provision purporting to do so shall be void and have no effect. [Add the following sentence as applicable to AHS purchases:] This Purchase Order incorporates Attachments E and F attached to the Participating Addendum.

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. 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. State The following is included to comply with Contractor’s procedural requirements. In the event that anything in the following letter may be construed to conflict with any other provision of this agreement, the other provision shall take precedence and shall be given operative effect. This letter is not intended to and does not impose any duty or obligation on any party beyond what is described elsewhere in this agreement, nor does it relieve any party of any duty or obligation described elsewhere in this agreement. Xxxxxx Xxxxxxxxxx, Commissioner Department of Vermont Participating Addendum No. #29990 Health Access 000 Xxxxxxxxx Xxxx Xxxxxxxxx, XX 00000 We are pleased to confirm our understanding of the services we are to provide for the Agency of Human Services, Department of Vermont health Access (“Participating Addendum”) Software Reseller Agreement Massachusetts Agreement No. ITS58 (“Master Agreement”) Purchase Order No. (Please refer to this assigned Purchase Order # on all correspondence, delivery documents and invoices.) This Purchase Order between the State of Vermont, CONTRACTING AGENCY (hereinafter the “State”) and CONTRACTOR NAME, ). We will examine the State’s compliance with principal place the requirements of business the six verifications set forth in CITY, STATE, Title 42 of the Code of Federal Regulations (hereinafter the “ContractorCFR”) is an agreement entered into §455, specifically section §455.304(d), relating to the Medicaid Disproportionate Share Hospital Payments Final Rule (“DSH Rule”) for the Medicaid State Plan rate years 2012. Our examination will be conducted in accordance with attestation standards established by the aboveAmerican Institute of Certified Public Accountants and in accordance with generally accepted governmental auditing standard as defined by the Comptroller General of the United States. Accordingly, it will include tests of records and other procedures we consider necessary to enable us to express an opinion regarding the State’s compliance with the six verifications set forth in Title 42 CFR §455.304(d). Those procedures will incorporate the auditor procedures detailed in the Centers for Medicaid & Medicare (“CMS”) General DSH Audit and Reporting Xxxxxxxx, XXX-0000-captioned Participating Addendum X. If, for any reason, we are unable to complete the examination, we will not issue a report as a result of this engagement. Our report will be intended solely for the information and Master Agreementuse of the State, the Vermont State Legislature, hospitals participating in the Vermont DSH program, and CMS, and is not intended to be, and should not be used by anyone other than those specified parties. Our engagement will not include a detailed inspection of every transaction and cannot be relied on to disclose all material errors, fraud, or other illegal acts, that may exist. However, we will inform the State of any material errors or fraud that comes to our attention. We will also inform the State of any other illegal acts that come to our attention, unless clearly inconsequential. We understand that the State will provide us with the basic information required for our examination and are responsible for the accuracy and completeness of that information. We may advise the State about appropriate criteria or assist in the development of the subject matter, but the responsibility for the subject matter remains with the State. At the end of the engagement, we will require a representation letter from management. The parties acknowledge and agree that all terms and conditions State is responsible for compliance with the requirements of the Participating Addendum six verifications set forth in Title 42 of the Code of Federal Regulations (“CFR”) §455, and Master Agreement (including respective amendments the reporting requirements under Title 42 CFR §447.299. The State is also responsible for making all management decisions and attachments therewith) are hereby incorporated by reference and shall apply to this Purchase Order as if specifically appended hereto. This Purchase Order shall not in any way amendperforming all management functions; for designating an individual who possesses suitable skill, conflict withknowledge, or supersede experience to oversee any non- attest services we may provide; and for evaluating the Participating adequacy and results of those services and accepting responsibility for them. Xxxx X. Xxxxxxx, MBA, CPA and Xxxx X. Xxxxxxxx, CPA are the engagement partners and are responsible for supervising the engagement and signing the report or authorizing another individual to sign it. Xxxxxxxx, Xxxxxxx & Associates, PLC Date of Request: Original Contractor Name: Contract #: Address: Phone Number: Contact Person: Agreement or Master 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, and any provision purporting to do so shall be void and have no effect. [Add the following sentence as applicable to AHS purchases:] This Purchase Order incorporates Attachments E and F attached to the Participating Addendum.not proceed further with approval until reviewed with Finance & Mgmt) Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature:______________________________ Phone Number: Approval: Title: Date:

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. 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. State INVOICE Agreement #: Address: Invoice #: Date of invoice: Billing Contact: Phone #: Dates of Service Description of Deliverables/Work Performed (please include/list a narrative of activities) Amount Project Management: Project Management Milestone: QI Facilitation: QI Facilitation Milestones: Self-Management Programs: Self-Management Master Trainer: Self-Management Completers ($200 each): Training, Travel, and Flexible Funding: Remittance Address: Xxxx to Address: Xxxxxxx Xxxxxxx Department of Vermont Participating Addendum No. Health Access 000 Xxxxxxxxx Xxxx, Xxxxx 000 Xxxxxxxxx, Xxxxxxx 00000-0000 Xxxxxxx.Xxxxxxx@xxxxxxx.xxx DVHA BO USE: *INVOICE PAYMENTS ARE NET00 TERMS, UNLESS STATED OTHERWISE* Date: TRAVEL AND FLEXIBLE FUNDING REQUEST FORM FINANCIAL REPORTING FORM DEPARTMENT OF VERMONT HEALTH ACCESS TRAVEL AND EXPENSE FORM DEPARTMENT OF VERMONT HEALTH ACCESS REQUEST FOR APPROVAL TO SUBCONTRACT Original Contractor/Grantee Name: Contract/Grant #29990 : 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 (“Participating Addendum”Note to Business Office: If Yes, do not proceed further with approval until reviewed with Finance & Mgmt) Software Reseller Agreement Massachusetts Agreement No. ITS58 (“Master Agreement”) Purchase Order No. (Please refer Dollar Amount of Subcontracted Services: $ Date Range for Subcontracted Services: Start: End: DVHA Contact Person: Signature: Phone Number: Comments: Approval: Title: Date: also ensure, to the full extent required by the Americans with Disabilities Act of 1990, as amended, that qualified individuals with disabilities receive equitable access to the services, programs, and activities provided by the Party under this assigned Purchase Order # on all correspondence, delivery documents and invoices.) This Purchase Order between the State of Vermont, CONTRACTING AGENCY (hereinafter the “State”) and CONTRACTOR NAME, with principal place of business in CITY, STATE, (hereinafter the “Contractor”) is an agreement entered into in accordance with the above-captioned Participating Addendum and Master Agreement. The parties acknowledge and agree that Party further agrees to include this provision in all terms and conditions of the Participating Addendum and Master Agreement (including respective amendments and attachments therewith) are hereby incorporated by reference and shall apply to this Purchase Order as if specifically appended hereto. This Purchase Order shall not in any way amend, conflict with, or supersede the Participating Agreement or Master Agreement, and any provision purporting to do so shall be void and have no effect. [Add the following sentence as applicable to AHS purchases:] This Purchase Order incorporates Attachments E and F attached to the Participating Addendumsubcontracts.

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. 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. As a Contractor for the State of Vermont Participating Addendum Vermont, I affirm that I have read the Agency of Human Services (AHS) Rule No. #29990 (“Participating Addendum”) Software Reseller Agreement Massachusetts Agreement 96-23 concerning Access to Information, and that I agree to comply with the requirements of AHS Rule No. ITS58 (“Master Agreement”) Purchase Order No96-23. (Please refer to this assigned Purchase Order CHANGE # on all correspondence, delivery documents 2 It is agreed by and invoices.) This Purchase Order between the State of Vermont, CONTRACTING AGENCY Department of Corrections (hereinafter the hereafter called “State”) and CONTRACTOR NAMEPublic Communication Services (PCS) of Los Angeles, with principal place of business in CITY, STATE, CA (hereinafter the hereafter called “Contractor”) that contract #10314 dated October 1, 2006 between said State and Contractor is an agreement entered into in accordance with the above-captioned Participating Addendum hereby amended as follows: To change Page 1, 4. Contract Term, from end on 09/30/2008 to end on 09/30/2009. Additionally, it is hereby agreed and Master Agreementunderstood that this contract has no minimum amount. The parties acknowledge and agree that all terms and conditions of the Participating Addendum and Master Agreement (including respective amendments and attachments therewith) are hereby incorporated Contractors’ services will be required on an “as needed” basis. To replace existing Attachment C with new Attachment C, revised May 23, 2008. To replace existing Attachment F with new Attachment F, revised April 11, 2008. To replace page 1, number 7 to read, “This contract may be cancelled by reference and shall apply to this Purchase Order as if specifically appended hereto. This Purchase Order shall not either party by giving written notice at least 180 days in any way amend, conflict with, or supersede the Participating Agreement or Master Agreement, and any provision purporting to do so shall be void and have no effect. [Add the following sentence as applicable to AHS purchases:] This Purchase Order incorporates Attachments E and F attached to the Participating Addendumadvance.”

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. Contractors 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. State The scope of Vermont Participating Addendum No. #29990 (“Participating Addendum”) Software Reseller Agreement Massachusetts Agreement No. ITS58 (“Master Agreement”) Purchase Order No. (Please refer work is to this assigned Purchase Order # on all correspondence, delivery documents and invoices.) This Purchase Order between implement the State state of Vermont’s Policy on Patient Consent for Provider Access to VHIE, CONTRACTING AGENCY (hereinafter which was approved in October 2012. It covers all of VITL’s responsibilities under the “State”) policy, including providing patient education materials and CONTRACTOR NAMEanswering patient questions via a toll-free phone number, with principal place providing forms for health care organizations to use when obtaining written patient consent, providing a mechanism for health care organizations to confirm that they have received written consent, responding to patient requests for audit records, responding to patient requests to see their individual information on the VHIE, periodically auditing provider consent records, reviewing all instances of business in CITYemergency access on the VHIE, STATE, (hereinafter the “Contractor”) is an agreement entered into in accordance with the above-captioned Participating Addendum and Master Agreementproviding a mechanism for providers to confirm that a patient has revoked consent. The parties acknowledge scope of work also covers provider outreach and agree that all terms and conditions of the Participating Addendum and Master Agreement (including respective amendments and attachments therewith) are hereby incorporated by reference and shall apply to this Purchase Order as if specifically appended hereto. This Purchase Order shall not in any way amendeducation, conflict with, or supersede the Participating Agreement or Master Agreementtraining, and any provision purporting support for using the ProAccess provider portal to do so shall be void and have no effect. [Add the following sentence as applicable to AHS purchases:] This Purchase Order incorporates Attachments E and F attached to the Participating Addendumview patient information after consent is obtained.

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. 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. State Date: _____ _ Original Contractor/Grantee Name: _____ _ Contract/Grant #: _____ _ Subcontractor Name: ____ _ Scope of Vermont Participating Addendum No. #29990 Subcontracted Services: _____ _____ _____ _____ _____ _ _____ Is any portion of the work being outsourced outside of the United States?  YES  NO (“Participating Addendum”If yes, do not proceed) Software Reseller Agreement Massachusetts Agreement No. ITS58 (“Master Agreement”) Purchase Order No. (Please refer to this assigned Purchase Order # on all correspondenceAll vendors under contract, delivery documents and invoices.) This Purchase Order between grant, or agreement with the State of Vermont, CONTRACTING AGENCY (hereinafter are responsible for the “State”) performance and CONTRACTOR NAME, with principal place compliance of business in CITY, STATE, (hereinafter the “Contractor”) is an agreement entered into in accordance their subcontractors with the above-captioned Participating Addendum Standard State Terms and Master Agreement. The parties acknowledge Conditions in Attachment C. This document certifies that the Vendor is aware of and agree that all terms in agreement with the State expectation and conditions of has confirmed the Participating Addendum and Master Agreement subcontractor is in full compliance (including respective amendments and attachments therewithor has a compliance plan on file) are hereby incorporated by reference and shall apply in relation to this Purchase Order as if specifically appended hereto. This Purchase Order shall the following:  Subcontractor does not owe, is in any way amend, conflict withgood standing, or supersede the Participating Agreement or Master Agreement, and is in compliance with a plan for payment of any provision purporting to do so shall be void and have no effect. [Add the following sentence as applicable to AHS purchases:] This Purchase Order incorporates Attachments E and F attached taxes due to the Participating Addendum.State of Vermont  Subcontractor (if an individual) does not owe, is in good standing, or is in compliance with a plan for payment of Child Support due to the State of Vermont.  Subcontractor is not on the State’s disbarment list. _____ Signature of Subcontractor Date _____ _____ Signature of Vendor Date _____ _____ _____ Received by DVHA Business Office Date APPENDIX 1: REQUIRED FORMS

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. 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. State Date: Original Contractor/Grantee Name: Contract/Grant #: Subcontractor Name: Amount: Scope of Vermont Participating Addendum No. #29990 Subcontracted Services: Is any portion of the work being outsourced outside of the United States?  YES  NO (“Participating Addendum”If yes, do not proceed) Software Reseller Agreement Massachusetts Agreement No. ITS58 (“Master Agreement”) Purchase Order No. (Please refer to this assigned Purchase Order # on all correspondenceAll vendors under contract, delivery documents and invoices.) This Purchase Order between grant, or agreement with the State of Vermont, CONTRACTING AGENCY (hereinafter are responsible for the “State”) performance and CONTRACTOR NAME, with principal place compliance of business in CITY, STATE, (hereinafter the “Contractor”) is an agreement entered into in accordance their subcontractors with the above-captioned Participating Addendum Standard State Terms and Master Agreement. The parties acknowledge Conditions in Attachment C. This document certifies that the Vendor is aware of and agree that all terms in agreement with the State expectation and conditions of has confirmed the Participating Addendum and Master Agreement subcontractor is in full compliance (including respective amendments and attachments therewithor has a compliance plan on file) are hereby incorporated by reference and shall apply in relation to this Purchase Order as if specifically appended hereto. This Purchase Order shall the following;  Subcontractor does not owe, is in any way amend, conflict withgood standing, or supersede the Participating Agreement or Master Agreement, and is in compliance with a plan for payment of any provision purporting to do so shall be void and have no effect. [Add the following sentence as applicable to AHS purchases:] This Purchase Order incorporates Attachments E and F attached taxes due to the Participating Addendum.State of Vermont  Subcontractor (if an individual) does not owe, is in good standing, or is in compliance with a plan for payment of Child Support due to the State of Vermont.  Subcontractor is not on the State’s disbarment list. Signature of Subcontractor Date Signature of Vendor Date Received by DVHA Business Office Date INVOICE Address: State: Zip Code: Invoice #: Date: Contract #: Contractor Billing Contact: Phone #: Month of Service Deliverable Due Date Xxxx if Complete Amount Task 1: Conduct Needs Assessment with Selected Participants: $5,000 Assessment tool Within 15 days of contract execution Assessment implementation Within 30 days of contract execution Assessment results and summary report Within 45 days of contract execution Task 2: Develop ACH Peer Learning Laboratory Plan and Curriculum: $5,000 High-level curriculum plan Within 30 days of contract execution Populated web-based peer learning platform Within 45 days of contract execution Task 3: Design and Facilitate Three Peer-to-Peer In-Person Learning Sessions: $81,000 Three peer-to-peer in-person learning session agendas (draft and final) Draft: 60 days prior to each session date Final: 45 days prior to each session date Session 1 Session 2 Session 3 Three complete sets of peer-to-peer in- person learning session materials (draft and final) Draft: 30 days prior to each session date Final: 7 days prior to each session date Session 1 Session 2 Session 3 Three in-person, day-long learning Date of session; first session prior to June Session 1 sessions for participating communities, including preparatory meetings and debrief meetings with design team 30, 2016 Session 2 Session 3 Three summary reports evaluating learning sessions Within 15 days of session Session 1 Session 2