HomeMy WebLinkAboutCORRESPONDENCE - PURCHASE ORDER - 9201730Work Order Form
Official Purchasing Form
Last updated 10/2017
WORK ORDER FORM
PURSUANT TO A MASTER AGREEMENT BETWEEN
THE CITY OF FORT COLLINS
AND
CSU EXTENSION LARIMER COUNTY CSU EXTENSION
WORK ORDER NUMBER: 2
PROJECT TITLE: Health Disparities Grant Program
ORIGINAL BID/RFP NUMBER & NAME: N/A – FLTI Sole Source
MASTER AGREEMENT EFFECTIVE DATE: December 1, 2019
WORK ORDER COMMENCEMENT DATE: June 30, 2020
WORK ORDER COMPLETION DATE: June 30, 2021
MAXIMUM FEE: (time and reimbursable direct costs): $50,000
PROJECT DESCRIPTION/SCOPE OF SERVICES: See attached cost spreadsheet
Service Provider agrees to perform the services identified above and on the attached forms in
accordance with the terms and conditions contained herein and in the Master Agreement between
the parties. In the event of a conflict between or ambiguity in the terms of the Master Agreement
and this Work Order (including the attached forms) the Master Agreement shall control.
The attached forms consisting of two (2) page(s) are hereby accepted and incorporated herein,
by this reference, and Notice to Proceed is hereby given after all parties have signed this
document.
SERVICE PROVIDER: Date:
Name, Title
ACCEPTANCE: Date:
Name, Project Manager
REVIEWED: Date:
Name, Buyer or Senior Buyer
ACCEPTANCE: Date:
Gerry Paul, Purchasing Director
(if greater than $60,000)
DocuSign Envelope ID: ECCC47C6-B5B4-481B-9509-F5DDE5F54597
11/19/2020
11/19/2020
11/19/2020
Project Name: Grant Amount:
Grant
Pay Period from: 1/7/2020 to: 1/6/2021
Partner Information: This does not reflect the total cost to implement FLTI only the cost the Grant is paying
Organization Contact Person Phone
Address Email Director
Month Staff time Description of Staff time Staff Cost
Facilitator
Payments
Recruiment
Hard Cost
Training Cost
FLTI
Tech Library
Assistance
FLTI
Interpretation
FLTI
Supplies for
FLTI Cohort
Total
July 2020 117.50
100-Site Coordinator and
17.50 - Co-Coordinator
1. 1- Attend Core team
meetings -work on Stake
holder Analysis recruitment
3.1 -Preparation for the
FLTI 2020 Cohort to
resume virtually &
Democracy in Action
engagemnet on affordable
housing
3.6- Recruitment of FLTI
Alumni and
underrepresented
populations
3167 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $3,267.00
August 2020 146.50
120-Site Coordinator and
26.50 - Co-Coordinator
1. 1- Attend Core team
meetings -work on Stake
holder Analysis -
recruitment
3.1- Preparation for the
FLTI 2020 Cohort to
resume virtually &
Democracy in Action
engagemnet on affordable
housing
3.6 Recruitment of FLTI
Alumni and
underrepresented
populations
3917 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $4,017.00
September 2020 120
120 - Site Coordinator and
20 - Co-Coordinator
1. 1- Attend Core team
Month Staff time Description of Staff time Staff Cost
Facilitator
Payments
Recruiment
Hard Cost
Training Cost
FLTI
Tech Library
Assistance
FLTI
Interpretation
FLTI
Supplies for
FLTI Cohort
Total
January 2021 120
80 - Site Coordinator and
10 - Co-Coordinator
1. 1- Attend Core team
meetings -work on Stake
holder Analysis -
recruitment
3.1 -Development and
implementation of civic
learning labs and engaging
alumni in community level
action around housing
affodability and health
equity.
3.6 recruit for
Home2Health Panels
3220 $500.00 $100.00 $1,000.00 $300.00 $5,120.00
February 2021 120
100 - Site Coordinator and
20 - Co-Coordinator
1. 1- Attend Core team
meetings -work on Stake
holder Analysis -
recruitment
3.1 -Development and
implementation of civic
learning labs and engaging
alumni in community level
action around housing
affodability and health
equity.
3.6 recruit for
Home2Health Panels
3220 $500.00 $100.00 $300.00 $4,120.00
March 2021 120
100 - Site Coordinator and
20 - Co-Coordinator
1. 1- Attend Core team
meetings -work on Stake
holder Analysis -
recruitment
3.1 -Development and
implementation of civic
learning labs and engaging
alumni in community level
action around housing
affodability and health
equity.
3.6 recruit for
Home2Health Panels
3220 $500.00 $100.00 $300.00 $4,120.00
April 2021 120
100 - Site Coordinator and
20 - Co-Coordinator
1. 1- Attend Core team
meetings -work on Stake
holder Analysis -
recruitment
3.1 -Development and
implementation of civic
learning labs and engaging
alumni in community level
action around housing
affodability and health
equity.
3.6 recruit for
Home2Health Panels
3220 $500.00 $100.00 $300.00 $4,120.00
May of 2021 120
100 - Site Coordinator and
20 - Co-Coordinator
1. 1- Attend Core team
meetings -work on Stake
holder Analysis -
recruitment
3.1 -Development and
implementation of civic
learning labs and engaging
alumni in community level
action around housing
affodability and health
equity.
3.6 recruit for
Home2Health Panels
3220 $500.00 $100.00 $300.00 $4,120.00
June 2021 120
100 - Site Coordinator and
20 - Co-Coordinator
1. 1- Attend Core team
meetings -work on Stake
holder Analysis -
recruitment
3.1 -Development and
implementation of civic
learning labs and engaging
alumni in community level
action around housing
affodability and health
equity.
3.6 recruit for
Home2Health Panels
3220 $100.00 $3,320.00
Total $38,584.00 $4,100.00 $900.00 $0.00 $2,500.00 $3,300.00 $50.00 $49,434.00
Approved:
Notes:
ADVANCES $0.00
TOTAL $49,434.00
Page 2 of 2
DocuSign Envelope ID: ECCC47C6-B5B4-481B-9509-F5DDE5F54597
meetings -work on Stake
holder Analysis -
recruitment
3.1 -Reconvene virtually
the 2020 20-week
language justice cohort of
the FLTI civic leadership
curriculum hosted on Zoom
3.6 recruit for
Home2Health Panels
3220 $100.00 $1,500.00 $600.00 $5,420.00
October 2020 120
120 - Site Coordinator and
20 - Co-Coordinator
1. 1- Attend Core team
meetings -work on Stake
holder Analysis -
recruitment
3.1 -Reconvene virtually
the 2020 20-week
language justice cohort of
the FLTI civic leadership
curriculum hosted on Zoom
3.6 recruit for
Home2Health Panels
3220 $600.00 $3,820.00
November 2020 120
120 - Site Coordinator and
20 - Co-Coordinator
1. 1- Attend Core team
meetings -work on Stake
holder Analysis -
recruitment
3.1 -Reconvene virtually
the 2020 20-week
language justice cohort of
the FLTI civic leadership
curriculum hosted on Zoom
3.6 recruit for
Home2Health Panels
3220 $1,600.00 $600.00 $50.00 $5,470.00
December 2020 90
80 - Site Coordinator and
10 - Co-Coordinator
1. 1- Attend Core team
meetings -work on Stake
holder Analysis -
recruitment
3.1 -Work on development
of civic learning labs and
engaging alumni in
community level action
around housing affodability
and health equity.
3.6 recruit for
Home2Health Panels
2520 $2,520.00
1525 Blue Spruce Dr. Fort Collins, CO 80524
CDPHF Grant: Housing Affordability and
Health Equity
CSU Extension - FLTI Larimer County
Kerri Rollins
(970)498-6013
auerlm@larimer.org
Lisa Auer
$50,000.00
For Office Use Only
Projected FLTI Larimer County
DocuSign Envelope ID: ECCC47C6-B5B4-481B-9509-F5DDE5F54597