CTR031658_-_OSU_Nisonger_Center_Executed.pdf

Contract (v.6.25) Drafted 7.1.2025

Contract # CTR031658

Ohio Department of Developmental Disabilities

PERSONAL SERVICE CONTRACT

SECTION A. CONTRACT PARTIES

This Contract is entered into between the Ohio Department of Developmental Disabilities (Agency), on behalf of the following:

Developmental Center / Central Office Division:

Residential Resources / All 8 Developmental Centers

Address (Street, City, State, Zip) 30 E. Broad Street, 13th fl.

Columbus, OH 43215 and

Contractor’s Name:

The Ohio State University, on behalf of the Nisonger Center

Address (Street, City, State, Zip) 1581 Dodd Drive Columbus, OH 43210

OAKS Supplier ID:

Type of Service:

Behavior Assessment & Consultation for Residents at DCs

SECTION B. TERM

1. The work described in this Contract shall commence on July 1, 2025. All activities under this Contract shall be completed not later than June 30, 2026, upon which this Contract shall expire unless terminated prior thereto pursuant to Section G. In the event that the work hereunder is to be done in separate phases, each phase shall be completed within the time prescribed in Appendix I.

Work shall not begin until Agency receives an Office of Budget and Management (OBM) approved Purchase Order.

SECTION C. COMPENSATION

1. In consideration of the promises of the Contractor herein, the Agency agrees to pay Contractor at the rates set forth in Appendix I on a reimbursement basis upon the Agency’s receipt and approval of proper invoices. Contractor shall not be compensated for services except as expressly set forth herein.

The total compensation to be paid to the Contractor under this Contract shall not exceed ten thousand forty seven dollars and zero cents ($10,047.00).

2. Contractor shall be solely responsible for all office, business, and personnel expenses associated with the performance of this Contract.

3. If “travel expenses” as defined by Ohio Administrative Code Section 126-1-02, are within the Scope of Work in Appendix I, Contractor shall only be reimbursed for those permissible travel expenses in accordance with the provisions of Ohio Administrative Code Section 126-1-02, in effect at the time Contractor renders the services. For this Contract the Agency agrees to pay Contractor an hourly rate for travel time required to the developmental center, which will cover all related travel expenses versus reimbursement.

4. Contractor shall be required to submit proper invoices that are itemized and contain all of the following:

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a. An itemization of the services performed, the material supplied, and/or labor furnished as described in Appendix I;

b. Date(s) of the rendering of the services;

c. Identification of the Individual (first name, first initial of last name) and residing

Developmental Center;

d. The sum due pursuant to the invoice for compensation owed under the Contract;

e. Invoice date and invoice number;

f. Contractor’s name and remit to address; and

g. “Bill to” must list the Agency’s name and address.

The adequacy and sufficiency of such invoices shall be determined solely by the Agency. If the Agency determines that an invoice is inadequate or insufficient or determines that further documentation or clarification is required for a particular invoice, the burden of providing the required information or documentation is on Contractor. Costs incurred by Contractor associated with providing the required additional information or documentation or related to defending an inadequate or insufficient invoice shall not be charged to the Agency and are not considered an allowable expense under the Contract.

5. Contractor shall submit invoice(s) and supporting documentation, if applicable, to the Agency via email at Accts.Payable@dodd.ohio.gov. The subject of the email should contain the Contractor’s Name, Invoice Number, and Invoice Date. All invoices must be submitted to the Agency no later than November 1st immediately after the close of the fiscal year in which services are provided.

6. Agency shall pay Contractor within thirty (30) days of receipt of an approved invoice.

SECTION D. STATEMENT OF WORK

1. Contractor shall undertake and complete the work and activities set forth in Appendix I: Scope of Work, which is attached hereto, made a part hereof, and incorporated herein by reference as if fully rewritten herein. Contractor shall consult with personnel of the Agency and with other appropriate persons, agencies, or instrumentalities as necessary to ensure a complete understanding of the work and satisfactory completion thereof.

2. Contractor shall maintain all necessary licenses or registrations. Contractor shall perform all services with reasonable care, skill and diligence as would normally be provided by an experienced consultant and in accordance with industry standards.

3. Agency may, as it deems appropriate and necessary, communicate specific instructions and requests to Contractor concerning the performance of the work described in this Contract. Upon such notice and within a reasonable time, Contractor shall comply with such instructions and fulfill such requests to the satisfaction of the Agency. It is expressly understood by the parties that the instructions and requests are for the sole purpose of performing the specific tasks outlined in the Scope of Work and to ensure satisfactory completion of the work described in this Contract. However, they are not intended to amend or alter the terms of the Contract or any part thereof. The management of the work, including the exclusive right to control or direct the manner or means by which the work is performed, remains with the contractor. Contractor has the right to deny instructions and requests that it deems would substantially alter the terms of the Contract or exceed the compensation agreed to between the parties.

SECTION E. NATURE OF CONTRACT

1. Agency enters into this Contract in reliance upon Contractor’s representations that it has the necessary expertise and experience to perform its obligations hereunder, and Contractor warrants that it does possess the necessary expertise and experience. It is specifically understood that the nature of the

Contract # CTR031658 services to be rendered under this Contract are of such a personal nature that Agency is the sole judge of the adequacy of such services. Agency thus reserves the right to terminate this Contract should Agency at any time be dissatisfied with Contractor’s performance of its duties under this Contract.

2. In the event of a termination of this Contract by Agency, Contractor shall be reimbursed in accordance with Section G.

SECTION F. CERTIFICATION OF FUNDS

It is expressly understood and agreed by the parties that none of the rights, duties, and obligations described in this Contract shall be binding on either party until all relevant statutory provisions of the Ohio Revised Code (O.R.C.), including, but not limited to, O.R.C. Section 126.07, have been complied with, and until such time as all necessary funds are available or encumbered and, when required, such expenditure of funds is approved by the Controlling Board of the State of Ohio, or in the event that grant funds are used, until such time that Agency gives Contractor written notice that such funds have been made available to Agency by Agency’s funding source.

SECTION G. TERMINATION OF CONTRACT

1. Agency may, at any time prior to the completion of services by Contractor under this Contract, suspend or terminate this Contract with or without cause by giving twenty (20) days written notice to Contractor.

2. Contractor, upon receipt of notice of suspension or termination, shall cease work on the suspended or terminated activities under this Contract, take all necessary or appropriate steps to limit disbursements and minimize costs, and, if requested by Agency, furnish a report, as of the date of receipt of notice of suspension or termination, describing the status of all work under this Contract, including, without limitation, results, conclusions resulting therefrom, and any other matters Agency requires.

3. Contractor shall be paid for services rendered up to the date Contractor received notice of suspension or termination, less any payments previously made, provided Contractor has supported such payments with invoices as required under Section C. In the event of suspension or termination, any payments made by Agency for which Contractor has not rendered services shall be refunded.

4. In the event this Contract is terminated prior to its completion, Contractor, upon payment as specified, shall deliver to Agency all work products and documents which have been prepared by Contractor in the course of providing services under this Contract. All such materials shall become and remains the property of Agency, to be used in such manner and for such purpose as Agency may choose.

5. Contractor agrees to waive any right to, and shall make no claim for, additional compensation against Agency by reason of such suspension or termination.

6. Contractor may terminate this Contract with or without cause upon thirty (30) days prior written notice to Agency.

SECTION H. INDEPENDENT CONTRACTOR

1. No relationship of employer and employee is created by this Contract. Contractor will act hereunder as an independent contractor with no claim under this Contract or otherwise against Agency for business expenses, travel expenses, vacation pay, sick pay, retirement benefits, workers compensation, or disability or unemployment insurance benefits or employee benefits of any kind.

Agency shall withhold no payroll or employment taxes of any kind.

Contract # CTR031658

2. Contractor is solely responsible for all of Contractor’s business expenses, including the payment or withholding of all federal, state and local income taxes, workers compensation insurance, social security and unemployment insurance, and the payment of wages and salaries, travel expenses, insurance of every kind, and health and retirement plans.

SECTION I. RECORD KEEPING

1. Until the expiration of six (6) years after the termination of this Contract, Contractor will, upon proper request, allow Agency, the Comptroller General of the United States, the U.S. Department of Health and Human Services, the State of Ohio, the Ohio Medicaid Fraud Control Unit and the Ohio Department of Medicaid and their duly-authorized representatives access to Contractor's books, documents and records necessary to certify the nature and extent of costs of reimbursable services provided under this Contract. For each subcontract in excess of $10,000, the Contractor shall require the subcontractor to agree to these record keeping provisions. If Contractor is requested to disclose any books, documents or records relevant to this Contract for the purpose of an audit or investigation by any government agency, Contractor shall immediately notify Agency of the nature and scope of the request and shall make available to Agency all books, documents and records relevant to the request.

2. All provisions under this section survive the expiration, suspension, or termination of this Contract.

SECTION J. CONFLICTS OF INTEREST, ETHICS, AND LEGAL COMPLIANCE

1. No personnel of Contractor who exercise any functions or responsibilities in connection with the review or approval of this Contract or carrying out of any of the Work shall, prior to the completion of the Work, voluntarily acquire any personal interest, direct or indirect, which is incompatible or in conflict with the discharge and fulfillment of his or her functions and responsibilities with respect to the carrying out of the Work. Any such person who acquires an incompatible or conflicting personal interest on or after the effective date of this Contract, or who involuntarily acquires any such incompatible or conflicting personal interest, shall immediately disclose his or her interest to the Agency in writing. Thereafter, he or she shall not participate in any action affecting the Work, unless the Agency shall determine in its sole discretion that, in light of the personal interest disclosed, his or her participation in any such action would not be contrary to the public interest.

2. Contractor represents, warrants, and certifies that it and its employees engaged in the administration or performance of this Contract are knowledgeable of and understand the Ohio Ethics and Conflicts of Interest laws. Contractor further represents, warrants, and certifies that neither Contractor nor any of its employees engaged in the administration or performance of this Contract will do any act that is inconsistent with such laws.

3. Contractor represents and warrants that all applicable parties listed in Division (I) or (J) of O.R.C.

Section 3517.13 are in full compliance with Divisions (I) and (J) of O.R.C. Section 3517.13.

4. Contractor represents and warrants that it is not subject to an "unresolved" finding for recovery under

O.R.C. Section 9.24. If this warranty is found to be false, this Contract is void ab initio and Contractor shall immediately repay to Agency any funds paid under this Contract.

5. Contractor represents and warrants that it is not debarred from consideration for contract awards by any state agency pursuant to either O.R.C. Section 125.25, O.R.C. 153.02, O.R.C. 5513.06, or any other provision of the Ohio Revised Code. If this representation and warranty is found to be false, this Contract is void ab initio and Contractor shall immediately repay to Agency any funds paid under this Contract.

Contract # CTR031658

6. Contractor represents and warrants that to its knowledge neither it nor any of its employees or agents are excluded from participation under any Federal health care program, as defined under 42 U.S.C.

Section 1320a-7b(D), for the provision of items or services for which payment may be made under a Federal health care program; Contractor has not arranged or contracted (by employment or otherwise) with any employee, contractor or agent that Contractor knows is excluded from participation in any Federal health care program, and no final adverse action, as defined under 42 USC Section 1320a- 7e(g) has occurred or is pending against Contractor or to its knowledge against any employee contractor or agent engaged to provide items or services under this Contract (collectively, "Exclusions/Adverse Actions"). Contractor shall notify Agency of any Exclusions/Adverse Actions within five (5) business days of its learning of such Exclusions/Adverse Actions.

7. Contractor shall comply with all applicable federal, state and local laws regarding smoke-free and drug-free work places and shall make a good faith effort to ensure that none of its employees or permitted subcontractors engaged in the work being performed hereunder purchase, transfer, use, or possess illegal drugs or alcohol, or abuse prescription drugs in any way.

8. Contractor warrants that it has not entered into, nor shall it enter into, other Contracts, without prior written approval of Agency, to perform substantially identical work for the State of Ohio such that the product contemplated hereunder duplicates the work called for by the other Contracts.

9. Contractor affirms that it has all of the approvals, licenses, or other qualifications needed to conduct business in Ohio and that all are current. If at any time during the term of this Contract, Contractor, for any reason, becomes disqualified from conducting business in the State of Ohio, Contractor will immediately notify the Agency in writing and will immediately cease performance of work.

10. Contractor represents and warrants that to its knowledge neither it nor any of its employees or agents in a direct services position has been convicted of any offense set forth in O.R.C. Section 5123.081(A) (4).

SECTION K. NONDISCRIMINATION

1. Pursuant to O.R.C. Section 125.111, Contractor agrees that Contractor, any subcontractor, and any person acting on behalf of Contractor or a subcontractor, shall not discriminate, by reason of race, color, religion, sex, age, national origin, veteran status, or disability against any citizen of this state in the employment of any person qualified and available to perform the work under this Contract.

2. Contractor further agrees that Contractor, any subcontractor, and any person acting on behalf of

Contractor or a subcontractor shall not, in any manner, discriminate against, intimidate, or retaliate against any employee hired for the performance of work under this Contract on account of race, color, religion, sex, age, national origin, veteran status or disability.

3. Pursuant to O.R.C. Section 125.111, Contractor shall maintain a written affirmative action program for the employment and effective utilization of economically disadvantaged persons and shall file a description of the affirmative action program and a progress report on its implementation with the equal employment opportunity office of the Department of Administrative Services.

4. Contractor shall not discriminate in the provision of services on account of race, color, religion, sex, age, natural origin, veteran status or disability.

SECTION L. LIABILITY

1. Each party shall accept and be responsible for its own negligent acts and omissions, as well as those of its employees discharging its obligation under this contract. Nothing in this contract, shall be

Contract # CTR031658 interpreted or construed to place any responsibility for acts or omissions of one party or its employees onto the other party.

2. In no event shall either party be liable to the other party for indirect, consequential, incidental, special, or punitive damages, or lost profits.

SECTION M. COMPLIANCE WITH LAWS

1. Contractor, in the execution of duties and obligations under this Contract, agrees to comply with all applicable federal, state and local laws, rules, regulations and ordinances, along with all applicable Agency policies.

2. PROHIBITION OF THE EXPENDITURE OF PUBLIC FUNDS FOR OFFSHORE

SERVICES. No State Cabinet Agency, Board or Commission will enter into any contract to purchase services provided outside of the United States or that allows State data to be sent, take, accessed, tested, maintained, backed-up, stored, or made available remotely outside (located) of the United States, unless a duly signed waiver from the State has been attained. Notwithstanding any other terms of this Contract, the State reserves the right to recover any funds paid for services the Contractor performs outside of the United States for which it did not receive a waiver. The State does not waiver any other rights or remedies provided to the State in the Contract.

Further, no State agency, board, commission, State educational institution, or pension fund will make any purchase from or investment in any Russian institution or company. Notwithstanding any other terms of this Contract, the State reserves the right to recover any funds paid to Contractor for purchases or investments in a Russian institution or company in violation of this paragraph. The provisions of this paragraph will expire when the applicable Executive Order (2022-02D) is no longer effective.

The Contractor must complete the attached Contractor/Subcontractor Affirmation and Disclosure Form (2019-12D & 2022-02D) affirming the Contractor understands and will meet the requirements of the above prohibition. During the performance of this Contract, if the Contractor changes the location(s) disclosed on the Affirmation and Disclosure Form, Contractor must complete and submit a revised Affirmation and Disclosure Form reflecting such changes.

3. The Department of Developmental Disabilities recognizes the safety of employees and contractors within Central Office and any of the agency’s Developmental Centers. In accordance with State of Ohio Administrative Policy HR-42 “Response to Active Aggressor”, every employee of the contractor providing services at the Offices of the Ohio Department of Developmental Disabilities under this Contract shall enroll and complete the online “Active Aggressor Response” training within thirty (30) days of the date employee’s initiation of services on site.

SECTION N. CONFIDENTIALITY

1. Contractor agrees that all data, reports and information received from Agency shall be used only for the services to be provided under this Contract. Contractor agrees that all discussions with Agency personnel and all reports prepared by Contractor are confidential. Contractor agrees to maintain the confidentiality of all such information and will not release such information without the prior written authorization of Agency or as required by law. If Contractor becomes subject to compulsory process to disclose any such information, Contractor shall immediately notify Agency of such process and the opportunity to contest any disclosure.

2. Notwithstanding the foregoing, it is expressly understood by the Parties that Contractor is subject to the Ohio Public Records Act, R.C. 149.43, et seq., and that any record kept by Contractor that is

Contract # CTR031658 deemed a public record is subject to release if a proper request is made.

3. Contractor IS or IS NOT a "business associate" pursuant to the definition under the Health

Insurance Portability and Accountability Act (HIPAA) and the regulations promulgated thereunder specifically 45CFR160.03. If Contractor is a business associate, then Contractor shall comply with Addendum A and every employee of the Contractor providing services under this Contract shall enroll in and complete the online DODD-HIPAA Training located in the MyLearning Portal on the dodd.ohio.gov website within 90 days of that employee’s initiation of services.

4. All provisions under this section survive the expiration, suspension, or termination of this Contract.

SECTION O. ENTIRE CONTRACT/WAIVER

1. This Contract contains the entire Contract between the parties hereto and shall not be modified, amended or supplemented, or any rights herein waived, unless specifically agreed upon in writing by the parties hereto.

2. This Contract supersedes any and all previous Contracts, whether written or oral, between the parties.

3. A waiver by any party of any breach or default by the other party under this Contract shall not constitute a continuing waiver by such party of any subsequent act in breach of or in default hereunder.

SECTION P. NOTICES

All notices, consents, and communications hereunder shall be given in writing, shall be deemed to be given upon mailing and shall be sent to the addresses set forth below:

Ohio Department of Developmental Disabilities Attn: Legal Counsel 30 East Broad Street, 12th Floor Columbus, Ohio 43215

The Ohio State University Nisonger Center Attn: Ashley Weiss, Business Operations Analyst 1581 Dodd Drive, 357 McCampbell Hall Columbus, Ohio 43210

With a copy to:

The Ohio State University Wexner Medical Center Attn: Senior Associate General Counsel Meiling Hall, Suite 200 370 W. 9th Avenue Columbus, OH 43210

Notwithstanding the forgoing, ordinary communications regarding the status of services being provided by Contractor may be sent by electronic mail to the designated representatives of Agency and Contractor.

SECTION Q. SEVERABILITY

Contract # CTR031658

The provisions of this Contract are severable and independent, and if any such provision shall be determined to be unenforceable in whole or in part, the remaining provisions and any partially enforceable provision shall, to the extent enforceable in any jurisdiction, nevertheless be binding and enforceable.

SECTION R. CONTROLLING LAW

This Contract and the rights of the parties hereunder shall be governed, construed, and interpreted in accordance with the laws of the State of Ohio and only Ohio courts shall have jurisdiction over any action or proceeding concerning the Contract and/or performance thereunder.

SECTION S. SUCCESSORS AND ASSIGNS

Neither this Contract nor any rights, duties or obligations hereunder may be assigned or transferred in whole or in part by Contractor, without the prior written consent of Agency.

SECTION T. INCORPORATION of ANCILLARY DOCUMENTS

Standard Affirmation and Disclosure Form (EO 2019-12D & 2022-02D)

Addendum A Business Associate Addendum B Duties Related to Direct Services Position

SECTION U. SIGNATURES

The Agency will accept either 1) a wet signature or 2) an electronic signature using OneSpan.

To execute the contract with a wet signature, Contractor may print the Contract, sign the contract, and scan the agreement and email it back to DDDProcurement@dodd.ohio.gov.

To execute the Contract electronically, using the electronic signature solution, OneSpan, Contractor shall inform DODD of its intent to sign the Contract electronically. DODD will then transmit Contractor to the signatory who may complete and sign the document(s) as required using OneSpan. The signatory will receive a notification via email from OneSpan when a copy of the fully executed Contract is available for download.

DODD has approved and will accept electronic signatures using DocuSign.

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IN WITNESS WHEREOF, the parties hereto have caused this Contract to be executed by their duly authorized officers, as of the day and year first written above.

Nisonger Center, The Ohio State University Ohio Department of Developmental Disabilities Marc J. Tasse’ Ph.D., Director Lyndsay Nash, Acting Director

By:______________________________ By:__________________________________

Date:_________________________________ Date:________________________________

Ohio Department of Developmental Disabilities Kimberley Dedino, Deputy Director

By:__________________________________

Date:________________________________

Contract # CTR031658

Appendix I Scope of Work

Scope of Work / Deliverables:

OSU Nisonger Center will provide support to DODD for the benefit of individuals residing at any of DODD’s developmental centers, who have intellectual developmental disability (IDD) and complex behavioral needs which need to be evaluated in order to achieve safety, stability, and an improved quality of life for the individual.

Agency’s Developmental Centers covered under this contract, include:

Cambridge Developmental Center (CADC) Columbus Developmental Center (CDC)

Gallipolis Developmental Center (GDC)

Mount Vernon Developmental Center (MVDC)

Northwest Ohio Developmental Center (NODC)

Southwest Ohio Developmental Center (SODDC) Tiffin Developmental Center (TDC)

Warrensville Developmental Center (WDC)

The Contractor when delivering services to individuals residing in a Developmental Center, Contractor shall comply with all duties listed in Addendum B.

a. “Direct services position” means a position in which the Contractor has the opportunity to be alone with, or exercises supervision or control over one or more individuals with a developmental disability.

b. All services shall be performed in accordance with: (1) generally accepted standards of care in the community and the quality criteria adopted by the Agency; (2) policies of the Agency; (3) applicable rules and standards for the certification of an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

The Contractor will provide a functional behavior assessment (initial, annual, revision, as applicable) for any individual identified by DODD. This service will be completed by a behavior support specialist working for the Contractor. The focus will be on the behaviors of concern and shared with the individual’s team. Common information reviewed as part of the assessment includes, Current Individualized service plan (ISP) Psychological evaluation(s) Mental health diagnoses and treatment Health information, including prescription medications.

Recent changes to life circumstances Relevant incident reports Previous behavior strategies Team composition

For an initial assessment, the goal is for 60 working days from assignment to completion. This assessment typically includes the following:

Interviews with relevant people (parents, guardians, instructors, familiar residential staff, counselors, center-based behavior specialists, etc.

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Observations scheduled in all relevant settings; home, day programs, transportation, community outings, etc.to record problem behaviors, functional communication, and replacement skills, Collection of baseline data

Attend relevant primary care and psychiatry appointments (as applicable)

Send final Behavior Assessment Report to service coordinator, guardian and additional team members as requested via secure e-mail, fax or postal mail.

Assisting the service coordinator with interweaving strategies into the Individualized Service Plan (as requested)

Assist the service coordinator with presentation to Human Rights Committee (as requested)

Provide or facilitate initial training on behavior strategies for implementers (training new staff or re-training as needed), which shall include:

Identifying on a case-specific basis whether training can be delegated and to whom.

Identifying whether electronic training (PP or video recording) is appropriate and developing that training (if applicable).

Obtaining signatures of trained implementers and filing a copy with the service coordinator.

DODD may identify individuals residing in any of its eight (8) developmental centers that require a functional behavioral assessment. Contractor would then provide consultation with the service coordinator at the developmental center regarding how to better support the individual’s needs.

Dates of Services / Timeframes:

The term of this contract spans the fiscal year 2026. Fiscal year 2026 (FY 26) is July 1, 2025 – June 30, 2026.

Budget / Rates:

The Contractor shall submit invoices monthly identifying the services provided during the billing period and will include a breakdown of costs based on the services / deliverables listed below and provide a total cost for the invoice. (See Section C. 4 for details)

The time required for these services is highly variable based on the complexity of the needs of the individual. A behavior assessment typically takes between 12-30 hours to complete plus travel time. The maximum compensation for this contract is based on up to 85 hours (including services and travel time).

The agreed upon rates for services under this contract are listed below.

Fiscal Year

Services / Deliverables Bill Rate (if applicable)

2026 Behavior Assessment and Consultation (services billed in minute increments of $1.97 per minute)

$118.20 / hour

2026 Travel Time for Behavior Support Specialist $118.20 / hour

STANDARD AFFIRMATION AND DISCLOSURE FORM

EXECUTIVE ORDERS 2019-12D & 2022-02D

EO2019-12D & 2022-02D Form (rev. 3 2022)

Governing the Expenditure of Public Funds on Offshore Services & Response to Russia’s Unjust War

Contractor affirms that Contractor has read and understands the applicable Executive Orders regarding the prohibitions of performance of offshore services, locating State data offshore in any way, or purchasing from Russian institutions or companies.

The Contractor shall provide all the name(s) and location(s) where services under this contract will be performed and where data is located in the spaces provided below or by attachment. Failure to provide this information may result in no award. If the Contractor will not be using subcontractors, indicate “Not Applicable” in the appropriate spaces.

1. Principal location of business of Contractor:

(Address) (City, State, Zip)

Name/Principal location of business of subcontractor(s):

(Name) (Address, City, State, Zip)

(Name) (Address, City, State, Zip)

2. Location(s) where services will be performed by Contractor:

(Address) (City, State, Zip)

Name/Location where services will be performed by subcontractor(s):

(Name) (Address, City, State, Zip)

(Name) (Address, City, State, Zip)

3. Location where state data will be located, by Contractor:

(Address) (City, State, Zip)

Name/Location(s) where state data will be located by subcontractor(s):

(Name) (Address, City, State, Zip)

(Name) (Address, City, State, Zip)

STANDARD AFFIRMATION AND DISCLOSURE FORM

EXECUTIVE ORDERS 2019-12D & 2022-02D

EO2019-12D & 2022-02D Form (rev. 3 2022)

Contractor also affirms, understands, and agrees that Contractor and its subcontractors are under a duty to disclose to the State any change or shift in location of services performed by Contractor or subcontractors before, during, and after execution of any Contract with the State. Contractor agrees it shall so notify the State immediately of any such change or shift in location of its services. The State has the right to immediately terminate the contract, unless a duly signed waiver from the State has been attained by the Contractor to perform the services outside of the United States.

On behalf of the Contractor, I acknowledge that I am duly authorized to execute this Affirmation and Disclosure form and have read and understand that this form is a part of any Contract that Contractor may enter into with the Department and is incorporated therein.

By: ____________________________________

Print Name: _____________________________

Title: ___________________________________

Date: ___________________________________

ADDENDUM A

Business Associate Addendum

This Business Associate Addendum (the “Addendum”) is entered into by and between the Ohio Department of Developmental Disabilities ("Agency") and Contractor.

Whereas, Agency and Contractor are parties to an agreement entered into contemporaneously herewith (“Underlying Agreement”); and

Whereas, Agency, pursuant to the Underlying Agreement, provides Contractor with certain individually identifiable protected health information that is necessary for Contractor to perform the services called for in the Underlying Agreement and is subject to protection under the Health Insurance Portability and Accountability Act of 1996(“HIPAA”) and the Standards for Privacy of Individually Identifiable Health Information and Security Standards for the Protection of Electronic Protected Health Information, 45 C.F.R. Part 160 and Part 164 (“Rules”); and Subtitle D of the Hitech Act, American Recovery and Reinvestment Act of 2009; and

Whereas, the parties purpose for entering into this Addendum is to comply with the requirements of applicable laws and regulations, including but not limited to HIPAA, Hitech, and the Rules.

NOW, THEREFORE, in consideration of the forgoing and the promises and mutual covenants contained herein, the parties agree as follows:

1. Definitions. Unless otherwise provided in this Addendum, capitalized terms shall have the same meaning as set forth in the Rules.

2. Duties and Responsibilities of Contractor:

A. Contractor acknowledges and agrees that all protected health information (the “PHI”), as defined by the Rules, provided to Contractor by Agency is confidential and the property of Agency without regard to medium of storage or method of transmission of such information. Contractor agrees to keep all PHI confidential.

B. Except as otherwise limited in this Addendum, Contractor may use or disclose PHI necessary to perform functions, activities, or services for, or on behalf of, Agency as specified in the Underlying Agreement or for the proper management and administration of Contractor, provided that such use or disclosure would not violate the Rules if done by Agency.

C. Contractor agrees to take reasonable steps necessary to protect the security and confidentiality of PHI so as to enable Agency to comply with HIPAA, Hitech, the Rules and other laws relating to the privacy and security of PHI, which are now in force or which may hereafter be in force, including, without limitation, the following actions:

(1.) use or disclose PHI only as permitted or required by the Underlying Agreement and this Addendum, or as Required by Law; and

(2.) use appropriate safeguards to prevent use or disclosure of the PHI other than as provided for by the Underlying Agreement and this Addendum; and

(3.) implement reasonable processes to detect unauthorized disclosures of PHI and train its work force regarding these processes; and

(4.) to the extent practicable, mitigate any harmful effect that is known to Contractor of a use or disclosure of PHI by Contractor in violation of the requirements of the Underlying Agreement or this Addendum; and

(5.) promptly and in no case later than 10 days after discovery, report in writing to Agency any use or disclosure of the PHI not provided for by the Underlying Agreement or this Addendum, of which Contractor becomes aware. Contractor shall provide such other available information to Agency to enable it to notify individuals as required by Hitech; and

(6.) require any contractors or agents, including subcontractors, to whom Contractor provides PHI received from, or created or received by Contractor on behalf of Agency, to agree to the same restrictions and conditions that apply to Contractor pursuant to this Addendum; and

(7.) make its internal practices (including policies and procedures), books, and records relating to the use and disclosure of PHI received from, or created or received by Contractor on behalf of Agency, available to the Secretary of the Department of Health and Human Services (the “Secretary”) for purposes of determining Covered Entities compliance with the Rules. Contractor shall provide Agency with a copy of any PHI that Contractor provides to the Secretary concurrently with providing such PHI to the Secretary; and

(8.) within fifteen (15) days of receiving a written request from Agency, provide to Agency the information necessary for the Agency to make an accounting of disclosures of PHI about an Individual as necessary for Agency to comply with 45 C.F.R. 164.528; and

(9.) make available information necessary for Agency to respond to an Individual's request for access to PHI about them as is necessary for Agency to comply with 45 C.F.R. 164.524. Such information shall be made available within ten (10) ten days of receiving a written request from Agency for such information. In the event an Individual contacts Contractor, or its agents or subcontractors, directly requesting access to PHI, Contractor will not grant access to PHI but will notify Agency in writing within five (5) business days of such contact; and

(10.) within fifteen (15) days of receiving a written request from Agency, incorporate any amendments or corrections to PHI as necessary for Agency to comply with 45 C.F.R. 164.526. In the event an Individual contacts Contractor, or its agents or subcontractors, directly about making amendment to PHI, Contractor will not make any amendments to PHI but will notify Agency in writing within five (5) business days of such contact.

3. Security Rule Provisions. Contractor agrees to the following additional obligations in order that Agency may meet its obligations under HIPAA Security Rule, 45 C.F.R. Part 164, Subpart C, with respect to electronic PHI:

A. Contractor will employ appropriate administrative, technical, and physical safe guards to protect the confidentiality, integrity, and availability of the electronic PHI that it creates, receives, maintains, or transmits on behalf of Agency.

B. Contractor will Report to Agency any Security Incident of which it becomes aware.

C. Contractor will ensure that any agent, including a subcontractor, to whom it provides such electronic

PHI agrees to implement reasonable and appropriate safeguards to protect it.

4. Breach of Unsecured PHI. If Contractor discovers any Breach of Unsecured PHI (as the terms “Breach” and Unsecured” PHI” or “Unsecured Protected Health Information” are defined in 45 C.F. R. 164.402) that it accesses, maintains, retains, modifies, records, stores, destroys, or otherwise holds, uses, or discloses on behalf of Agency, then in accordance with 45 C.F.R. §164.410, Contractor shall notify Agency of such Breach in writing without unreasonable delay and in no event later than ten (10) days after discovery of such Breach, which written notice shall include, to the extent possible, the identification of each Individual whose Unsecured PHI has been, or is reasonably believed to have been, accessed, acquired, or disclosed during such Breach. In addition, Contractor shall provide Agency with the following information, to the extent available at the time initial notice to Agency is provided, or promptly thereafter as such information becomes available:

A. A brief description of what happened, including the date of the Breach and the date of the discovery of the Breach.

B. A description of the type of PHI that was involved (e.g., name, Social Security Number, procedure, diagnosis, treatment, etc.).

C. A brief description of the steps that Contractor is taking to investigate, mitigate harm, and protect against further Breaches.

5. Termination. Agency may immediately terminate the Underlying Agreement, including this Addendum, by giving Contractor written notice of termination, if Agency determines that Contractor has violated a material term of this Addendum. Alternatively, Agency may in its sole discretion provide an opportunity for Contractor to cure the breach and end the violation. If Contractor fails to cure the breach to the satisfaction of Agency, the Agency may immediately thereafter terminate the Underlying Agreement.

Termination of the Underlying Agreement shall result in the termination of this Addendum.

Contractor agrees that upon termination of the Underlying Agreement, it will return or destroy all PHI received from, or created or received on behalf of Agency, that Contractor still maintains in any form and retain no copies of such information. This provision shall apply to PHI that is in the possession of Contractor and any subcontractors or agents of Contractor. In the event that returning or destroying the PHI is infeasible, as determined by Agency, Contractor agrees to extend the protections of the Underlying Agreement and this Addendum to such PHI and limit further uses and disclosures of such PHI to those purposes that make the return or destruction infeasible, for so long as Contractor maintains such PHI.

6. Amendment. It is the intent of the parties that the Underlying Agreement and this Addendum comply with the requirements of HIPAA, Hitech, and the Rules. Any ambiguity in the Underlying Agreement or this Addendum shall be resolved to permit Agency to comply with HIPAA and the Rules. If necessary, the parties agree to use good faith efforts to amend the Underlying Agreement and this Addendum from time to time as is necessary for Agency to be in compliance with HIPAA and regulations promulgated thereunder.

7. Survival. The obligations of the Contractor under this Addendum shall survive the expiration or termination of the Underlying Agreement and this Addendum.

8. No Third Party Beneficiaries. Nothing express or implied in this Addendum is intended to confer, nor shall confer, upon any person other than the parties, and their permitted successors and assigns if any, rights, remedies, obligations or liabilities whatsoever.

9. Miscellaneous: As amended by this Addendum, the Underlying Agreement and all its terms and conditions shall remain in full force and effect.

Revised 5/2014

ADDENDUM B

Duties Related To Direct Service Positions

1. Background Check Requirements. The Contractor shall comply with the criminal background check requirements in Ohio Administrative Code 5123:2-2-02 including but not limited to data base check and criminal background check. The Contractor shall also ensure that each employee signs an agreement requiring notification if the employee is formally charged with, is convicted of or pleads guilty to a disqualifying offense.

2. Tuberculosis Testing

i. Staff employed shall be tested for tuberculosis in accordance with this paragraph. The required tuberculosis test shall include a two-step Mantoux tuberculin skin test administered by a person properly trained to administer tuberculin skin tests, or, if the person has a documented history of a significant Mantoux skin test, an x-ray. The person shall not work in the facility until after the results of the first skin test have been obtained and recorded in millimeters of in duration. If the first step is non-significant, a second step shall be performed at least seven, but not more than twenty-one, days after the first step was performed. Only a single Mantoux is required if the person has documentation of either a single-step Mantoux test or a two-step Mantoux test within one year of commencing work.

ii. If either step of the Mantoux test is significant, the person shall have a chest x-ray and shall not enter the residential facility until after the results of the chest x-ray have been obtained and the person is determined to not have active pulmonary tuberculosis.

Whenever a chest x-ray is required by this paragraph, a new chest x-ray need not be performed if the person has had a chest x-ray no more than thirty days before the date of the significant Mantoux test. Additional Mantoux testing is not required after one medically documented significant test. A subsequent chest x-ray is not required unless the person develops symptoms consistent with active tuberculosis.

iii. For persons with a significant Mantoux test and the chest x-ray does not indicate active pulmonary tuberculosis, the facility shall require that the person be evaluated and considered for preventive therapy. Thereafter, the facility shall require the person to report promptly any symptoms of tuberculosis which include unexplained weight loss, loss of appetite, chronic cough of more than three weeks, fever, coughing, and spitting up blood and night sweats. The facility shall annually document the presence or absence of symptoms suggestive of tuberculosis in such a person and maintain this documentation on file.

iv. After initial screening for tuberculosis required by this paragraph and annually thereafter within one year plus or minus thirty days of the previous year’s date of screening, a tuberculosis screening for symptoms suggestive of active tuberculosis shall be conducted for all habilitation and support staff. This screening shall include, at a minimum, questions about the signs and symptoms of tuberculosis as indicated in paragraph (B)(6)(b) of this rule. The frequency of any additional Mantoux skin test screenings or the need for a physician evaluation shall be dependent upon this assessment.

Revised 5/2014

3. Professional Staff Credentials. Professional program staff must be licensed, certified, or registered, as applicable by the state, to provide professional services in the field in which they practice.

4. The Contractor shall ensure that staff receive training in first aid, CPR and universal precautions to comply with the requirements established in rule 5123:2-3-08(B)(5) of the Administrative Code.

5. Contractor shall ensure that employees are at least 18 years of age.

6. Contractor shall ensure that employees receive annual written notice explaining conduct for which an employee may be included in the Registry established by R. C. 5123.542.

7. Contractor, if providing transportation, shall provide a copy of the vehicle insurance policy and have its employees, prior to being placed in direct services position provide a certified copy of abstract from the Ohio Bureau of Motor Vehicles.

8. Upon request, Contractor shall provide the Developmental Center with a copy of any report or abstract showing compliance with the above requirements.