117168-O4.pdf

DHHS Service Contract (Short Form) Page 1 of 5 Rev. 07/2021

SERVICE CONTRACT (SHORT FORM)

BETWEEN

THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES

AND

This contract, including any attachments (collectively, “Contract”) is entered into by and between the Nebraska

Department of Health and Human Services, ______________________________________________

(hereinafter “DHHS”), and _____________________________________________________________

(hereinafter “Contractor”).

PURPOSE: The purpose of this Contract is ________________________________________________

FUNDING: This Contract involves _______________________________

1. DURATION

1.1. TERM. This agreement begins on the later of ______________________ or the date this agreement is signed by the parties. This agreement ends on _______________________.

2. PAYMENT TERMS AND STRUCTURE

2.1. TOTAL PAYMENT. DHHS shall pay Contractor a total amount not to exceed

$__________________________ (_________________________________dollars) for the services specified herein.

2.2. INVOICING. Upon completion of all services and provision of all deliverables, Contractor shall invoice DHHS for the total amount set forth in 2.1, above. DHHS shall pay consistent with the terms provided herein.

2.2.1. Any term included in Contractor’s invoice shall be deemed to be solely for the convenience of the parties and is not binding on the parties. No payment shall be made for any deliverable or cost unless specifically authorized in the terms of the Contract.

2.3. PROMPT PAYMENT. Payment shall be made in compliance with the Nebraska Prompt Payment Act, Neb. Rev. Stat. §§ 81-2401 et seq. DHHS shall make payment in full for services provided on or before the forty-fifth (45th) calendar day after (a) the date of the completion of the service(s) or (b) the date of receipt by DHHS of the invoice for the service(s), whichever is later. Payment shall be

Docusign Envelope ID: 2B640969-28A9-891A-809E-666E92A2C585

Elkhorn Logan Valley Public Health Department

Elkhorn Logan Valley Public Health Department

29June for an Elkhorn Logan Valley Public Health Department staff member to become a Master

Trainer in Health Coaches for Hypertension Control (HCHC), capable of training leaders throughout the state to lead HCHC workshops in their communities.

2026September

Division of Public Health federal funds one thousand eight hundred sixty-seven

DHHS Service Contract (Short Form) Page 2 of 5 made by electronic means. The Contractor shall complete and sign the State of Nebraska ACH Enrollment Form and obtain the necessary information and signatures from their financial institution.

The completed form must be submitted before payments may be made.

Download ACH Form: http://das.nebraska.gov/accounting/nis/address_book_info.htm

3. SERVICES PROVIDED

3.1. DESCRIPTION OF SERVICES. The Contractor shall ____________________________________

3.2. DELIVERABLES. Contractor shall provide the following deliverables:________________________

4. GENERAL TERMS

4.1. ACCESS TO RECORDS. All Contractor books, records, and documents, regardless of physical form, including data maintained in computer files or on magnetic, optical or other media, relating to work performed or monies received under this Contract, shall be subject to audit by DHHS or its authorized representative at any reasonable time and upon the provision of reasonable notice. Contractor shall maintain all records for five (5) years from the date of final payment.

4.2. AMENDMENT. This Contract may only be modified by written amendment, executed by both parties.

No alteration or variation of the terms of this Contract shall be valid unless made in writing and signed by the parties.

4.3. CIVIL RIGHTS AND EQUAL OPPORTUNITY EMPLOYMENT. The Parties shall comply with all applicable local, state and federal law regarding civil rights, including but not limited to the Nebraska Fair Employment Practice Act, Neb. Rev. Stat. §§ 48-1101 to 48-1125.

4.4. COMPLIANCE WITH LAW. The Parties shall comply with all other applicable federal, state, county and municipal laws, ordinances, and rules and regulations in the performance of this Contract.

4.5. CONFIDENTIALITY. Any and all information gathered in the performance of this Contract, either independently or through DHHS, shall be held in the strictest confidence and shall be released to no one other than DHHS without the prior written authorization of DHHS. Contrary provisions set forth in the Contract shall be deemed to be authorized exceptions to this general confidentiality provision.

4.6. DRUG-FREE WORKPLACE. Contractor certifies that it maintains a drug-free workplace environment to ensure worker safety and workplace integrity. Contractor shall provide a copy of its drug-free workplace policy at any time upon request by DHHS.

4.7. FORCE MAJEURE. Neither party shall be liable for any costs or damages resulting from its inability to perform any of its obligations under this Contract due to a natural disaster, or other similar event outside the control and not the fault of the affected party.

4.8. INDEMNIFICATION. Contractor shall defend, indemnify, hold, and save harmless DHHS and its employees, volunteers, agents, and its elected and appointed officials (“the indemnified parties”)

Docusign Envelope ID: 2B640969-28A9-891A-809E-666E92A2C585

3.2.1: Submission of new HCHC Master Trainer certificate to the NE DHHS Chronic Disease

Prevention and Control team following the completion of the training.

3.2.2: Share plans, updates, or other progress towards a scheduled leader training.

3.1.1: Have an Elkhorn Logan Valley Public Health Department attend a Master Training for Health

Coaches for Hypertension Control (HCHC) in order to become capable of training leaders/coaches throughout the state to lead HCHC workshops in their communities.

3.1.2: The new Master Trainer will then make progress towards hosting a leader/coach training.

Progress may include but is not limited to recruiting new leaders/coaches, scheduling a leader/coach training, conducting a leader/coach training, and printing necessary materials for trainings and workshops.

http://das.nebraska.gov/accounting/nis/address_book_info.htm

DHHS Service Contract (Short Form) Page 3 of 5 from and against any and all claims, liens, demands, damages, liability, actions, causes of action, losses, judgments, costs, and expenses of every nature, including investigation costs and expenses, settlement costs, and attorney fees and expenses (“the claims”), sustained or asserted against DHHS, arising out of, resulting from, or attributable to the willful misconduct, negligence, error, or omission of Contractor, except to the extent such Contractor liability is attenuated by any action of the DHHS that directly and proximately contributed to the claims. DHHS’s liability is limited to the extent provided by the Nebraska Tort Claims Act, the Nebraska Contract Claims Act, the Nebraska Miscellaneous Claims Act, and any other applicable provisions of law. DHHS does not assume liability for the action of its contractors.

4.9. INDEPENDENT CONTRACTOR. It is mutually understood and agreed by the Parties that the Contractor is an independent contractor. Contractor will be responsible for the payment of any taxes or fees due because of payment for the service(s).

4.10. INTEGRATION. This written Contract, along with any attachments, represents the entire agreement between the parties, and any prior or contemporaneous representations, promises, or statements by the parties, which are not incorporated herein, shall not serve to vary or contradict the terms set forth in this Contract.

4.11. NEBRASKA NONRESIDENT INCOME TAX WITHHOLDING. Contractor acknowledges that Nebraska law requires DHHS to withhold Nebraska income tax if payments for personal services are made in excess of six hundred dollars ($600) to any contractor who is not domiciled in Nebraska or has not maintained a permanent place of business or residence in Nebraska for a period of at least six months. This provision applies to individuals, to a corporation if 80% or more of the voting stock of the corporation is held by the shareholders who are performing personal services, and to a partnership or limited liability company if 80% or more of the capital interest or profits interest of the partnership or limited liability company is held by the partners or members who are performing personal services.

4.11.1. The parties agree, when applicable, to properly complete the Nebraska Department of

Revenue Nebraska Withholding Certificate for Nonresident Individuals Form W-4NA or its successor. The form is available at:

http://www.revenue.nebraska.gov/tax/current/fill-in/f_w4na.pdf

4.12. NEW EMPLOYEE WORK ELGIBILITY STATUS. Contractor shall use a federal immigration verification system to determine the work eligibility status of new employees physically performing services within the State of Nebraska. A federal immigration verification system means the electronic verification of the work authorization program authorized by the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, 8 U.S.C. § 1324a, known as the E-Verify Program, or an equivalent federal program designated by the United States Department of Homeland Security or other federal agency authorized to verify the work eligibility status of a newly hired employee.

4.12.1. If Contractor is an individual or sole proprietorship, the following applies:

Contractor must complete the United States Citizenship Attestation Form, available on the Department of Administrative Services website at https://das.nebraska.gov.

If Contractor indicates on such attestation form that he or she is a qualified alien, Contractor agrees to provide the US Citizenship and Immigration Services documentation required to verify Contractor’s lawful presence in the United States using the Systematic Alien Verification for Entitlements Program.

Contractor understands and agrees that lawful presence in the United States is required and Contractor may be disqualified or the Contract terminated if such lawful presence cannot be verified as required by Neb. Rev. Stat. § 4-108.

4.13. SEVERABILITY. If any term or condition of this Contract is declared by a court of competent jurisdiction to be illegal or in conflict with any law, the validity of the remaining terms shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if this Contract did not contain the particular provision held to be invalid.

4.14. TERMINATION. DHHS and Contractor reserve the right to terminate this Contract at any time. Either party may terminate this Contract for convenience upon 10 (ten) days prior written notice to the other party. DHHS may terminate the Contract, in whole or in part, if Contractor fails to perform its obligations under the Contract in a timely and proper manner.

Docusign Envelope ID: 2B640969-28A9-891A-809E-666E92A2C585 http://www.revenue.nebraska.gov/tax/current/fill-in/f_w4na.pdf https://das.nebraska.gov/

DHHS Service Contract (Short Form) Page 4 of 5

5. CONTACT INFORMATION

DHHS Contract Manager Contractor

Name

Address Line 1

Address Line 2

City, State Zip

Phone

Email

Name

Address Line 1

Address Line 2

City, State Zip

Phone

Email

6. ACKNOWLEDGEMENT

If Contractor is an individual or sole proprietorship, then the Acknowledgement below is applicable.

Otherwise, disregard this section.

By signing below, Contractor certifies, acknowledges and agrees with the following statement:

I acknowledge and agree that I am an independent contractor. I further certify that I am not a current employee of the State of Nebraska. With this Contract, the State of Nebraska, Department of Health and Human Services, is not hiring me as a temporary, part-time, or permanent employee. I hereby waive any current or future claim to employment, employee protections under contract, rule or regulation, healthcare benefits, retirement, or other benefits offered now or in the future by the State of Nebraska.

PO Box 95026 sarah.godejohn@nebraska.gov

Lincoln, NE 68509-5026

(402) 471-0505

Sarah Godejohn melissa@elvphd.ne.gov

402-529-2233

Wisner, NE 68791

Elkhorn Logan Valley Public Health Department

P.O. Box 779

DHHS Service Contract (Short Form) Page 5 of 5

IN WITNESS THEREOF, the parties have duly executed this Contract hereto, and that the individual signing below has authority to legally bind the party to this Contract.

FOR DHHS: FOR CONTRACTOR:

Name Name

Title Title

Department of Health and Human Services Company

Division

DATE: ________________________ DATE: _________________________

Health Director

Gina Uhing

9/15/2026 | 13:45:00 CDT

Elkhorn Logan Valley Public Health Departme

Deputy Director

Sara Morgan

9/17/2026 | 08:17:55 CDT

of Public Health