CR 92-254 Environmental Health Services
e
.
.
1 y
o
December 7, 1992
v ....
m
'l <::>
o P K \ '"
Council Report No. 92-254
ENVIRONMENTAL HEALTH SERVICES AGREEMENT FOR 1993
Proposed Action.
Staff recommends the following motion: Move to aDo rove the
environmental health services aareement with Hennepin County for
1993.
Approval of this motion will allow the Mayor and City Manager to
execute an agreement with Hennepin County to allow Hopkins to
receive financial support from the County for environmental
health services.
Overview.
The State Health Department grants authority to Hennepin County
to provide for environmental health services in the County.
The County allows cities who wish to provide for there own health
services the authority to do so on a year by year basis. The city
has exercised this right and undertakes the inspection and
licensing of establishments such as restaurants, hotels, swimming
pools, etc.
Execution of the agreement with the County allows Hopkins to
continue to locally license certain establishment and the County
agrees to pay the city $2800.00 for direct support of the
activity.
The agreement is the standard agreement we execute with the
County each year.
Primary Issues to consider.
o Should the City continue to provide its own Health
services.
The cost to the City to provide our own health inspection
program is approximately $13,000 per year. The City receives
revenue through licensing of restaurants, lodging
establishments and swimming pools. This revenue more than
covers the costs of administering the program. Local
administration of the program provides Hopkins residents
personal attention and service. Staff feels it is in the
city's best interest to continue to provide its own health
services.
Information.
. of healt services agreement
'I
..
. City of Hopkins
Contract No. A03163
ENVIRONMENTAL HEALTH SERVICES AGREEMENT
THIS AGREEMENT is made and entered into by and between the COUNTY
OF HENNEPIN, STATE OF MINNESOTA, hereinafter referred to as the
"County", through its Community Health Department, hereinafter
referred to as the II Department" , and the city of Hopkins I a
Municipality organized and existing under the Laws of the State of
Minnesota, hereinafter referred to as the "Municipality".
WIT N E SSE T H:
WHEREAS, The Municipality wished to provide Community Health
Services; and
WHEREAS, County funds through the Department are available to
support such services and whereas community Heal th Services subsidy
funds are available from the Minnesota Department of Health:
.
NOW, THEREFORE, in consideration of the mutual undertakings and
agreements hereinafter set forth, the County through the Department
and the Municipality agree as follow:
1. TERM OF AGREEMENT
The term of this Agreement shall be from January 11 19931
through December 31, 1993, subject to cancellation provision
contained herein.
2. CONDITIONS OF COUNTY SUPPORT
A. The County through the Department agrees to make payments
to the Municipality for the provision of local
environmental health services (maintenance) as described
in Exhibit A, such Exhibit attached hereto and made a
part hereof as though fully set forth herein.
B. The total 1993 cash payments shall not exceed $2,800.00.
C. Payments to the Municipality will be made in two (2)
equal installments in the amount of $11400.00 to be paid
on or about July 11 19931 and January 1, 19941 upon
receipt of completed and signed Exhibits Band C,
attached hereto and made a part hereof as though fully
set forth herein. Payment shall be made within (35 days)
. HCA Form No. 104, Rev. 11/92
. 2
from receipt of the invoice. If the invoice lS
incorrect, defective, or otherwise improper, the County,
through the Department, will notify the Municipality
within ten (10) days of receiving the incorrect invoice.
Upon receiving the corrected invoice from the
Municipality, the County, through the Department, will
make payment within (35 days). In the event that the
County withholds payment for failure to provide service
or failure to comply with any of the provisions of this
Agreement, then no interest penalty shall accrue against
the County through the Department. If claims are made by
the Municipality that the County, through the Department,
did not act in good faith in withholding payments as
provided above, then such claims shall be handled as a
dispute by the Contract Manager (pursuant to clause 13 of
this Agreement). If an audit is required by the County,
through the Department, before payment is to be made,
then no interest penalty shall accrue against the County,
through the Department, until after (35 days) after the
audit is completed by the County.
D.
The Municipality agrees to make expenditure of county-
provided payment only for the purpose of providing the
environmental health services as described in Exhibit A
attached hereto.
e
E. The Municipality agrees to provide semi-annual reports to
the County through the Department within thirty (30) days
of July 1, 1993, and January 1, 1994, detailing revenues
and expenditure in accordance with Exhibit B attached
hereto.
F. The Municipality agrees to maintain a Delegation of
Authority Agreement with the Minnesota Department of
Health pursuant to Minnesota statutes 145A.07 to act as
the agent of the Minnesota Department of Health to
provide food protection services, lodging, and boarding
services of children's camp inspections. The
Municipality agrees to regulate public swimming pools
pursuant to Minnesota Rules Chapter 4717 relating to
public swimming pools, including all subsequent
amendments thereto. A copy of the Delegation of
Authority agreement is attached hereto and marked and
made a part of Exhibit A.
3. CONDITION OF THE PARTIES' OBLIGATIONS
.
A.
It is understood and agreed that the Agreement between
the parties is conditional upon the County receiving
sufficient funding from the State of Minnesota. If such
funding is not available, this agreement shall be
II 3
cancelled immediately upon written notice to the
Municipality, other provision for cancellation of this
Agreement notwithstanding. This Agreement may be
renegotiated to reflect any reduced funding.
B. Any material alterations, variations, modifications, or
waivers of provisions of this Agreement shall be valid
only when they have been reduced to writing as an
amendment to this Agreement signed by the parties hereto.
c. Upon cancellation or termination of this Agreement, the
Municipali ty will reimburse to the County through the
Department any and all unobligated funds as required by
the Minnesota Department of Health. This reimbursement
shall be made within sixty (60) days of the effective
date of such termination.
D.
In the event of any policy changes which result in a
reduction of services or major inconsistencies with the
1992-1995 Hennepin County Health Services Subsidy Plan
written pursuant to Minnesota statutes 1987, 145A.I0
Subdivisions 5 and 6, the Municipality will notify and
consult with the County through the Department before
implementing the new policy.
.
E. The Municipality shall comply with the provisions of the
Communicable Disease Reporting Rules adopted by the
Minnesota Department of Health in accordance with the
provision of Minnesota Rules, Chapter 4605, Parts 7000-
7600.
4. AUDITS. REPORTS. MONITORING PROCEDURES, AND RECORDS
A. The Municipality will:
(1) Maintain a bookkeeping system which sufficiently
and properly reflects all direct and indirect costs
of any nature expended in the performance of this
Agreement.
(2) Provide a semiannual budget/expenditure report
within thirty (30) days of July 1, 1993, and
January 1, 1994, to the county through the
Department detailing all revenues and expenses as
described in Exhibit B attached hereto.
.
(3) Provide a semiannual program activity report within
thirty (30) days of July 1, 1993, and
January 1, 1994, to the County through the
Department as described in Exhibit C attached
hereto.
. 4
.
.
(4) Submit a copy of the list of licensees to the
department which is furnished to the Commissioner
of Health as requested by the delegation of
authority agreement, The list will be subdivided
according to the definitions of risk level
specified in Minnesota statues 157.01-.04.
B. The Municipality agrees that the County, the state
Auditor or legislative authority, or any of their duly
authorized representatives at any time during normal
business hours, and as often as they may deem reasonably
necessary, shall have access to and the right to examine,
audit, excerpt, and transcribe any books I documents,
papers, records, etc. I and accounting procedures and
practices of the Municipality which are relevant to the
Contract. Such material must be retained for five (5)
years by the Municipality.
The County through the Department will monitor and
evaluate the performance of the Municipality under this
agreement on an ongoing basis. The municipality will
make complete inspections of licensed establishments at
least at the frequency required by Minnesota statutes
157.01-.04.
C.
5. DATA PRIVACY
A. All data collected, created, received, maintained, or
disseminated for any purposes by the activities of the
Municipali ty in the performance of this contract is
governed by the Minnesota Government Data Practices Act,
Minnesota Statutes 1992, the Minnesota Rules implementing
such Act now in force or hereafter adopted, as well as
federal regulations on data privacy.
B. In accordance with Minnesota Statues 1992, Section 13.46,
Subdivision 10, the Municipality shall appoint a
responsible authority who shall allow the responsible
authorities in the welfare system access to data
classified as restricted when access is necessary for the
administration and management of programs or as
authorized or required by State or Federal law. The
Municipality shall notify the county of the name of the
responsible authority.
6. EOUAL EMPLOYMENT OPPORTUNITY AND CIVIL RIGHTS
A.
During the performance of this
Municipality agrees to the following:
the
Agreement,
e 5
In accordance with the Hennepin County Board of
Commissioners; policies Against Discrimination, no person
shall be excluded from full employment rights, denied
access to or participation in the benefits of any
program, service or activity on the grounds of race,
color, creed, religion, age, sex, disability, marital
status, affectional/sexual preference, public assistance
status, ex-offender status or national origins; and no
person who is protected by applicable Federal or state
laws against discrimination and all regulations
implementing such laws, including but not limited to the
civil Rights Restoration Act of 1987, Public Law No. 100-
259, 102 stat 28-32, 1988 and 20 USC 1681 ET. SEQ., 42
USC 2000D and 29 USC 706 shall be otherwise subjected to
discrimination.
.
(1) The Municipality shall comply with all applicable
statues, regulations, and licensing requirements in
the employment of personnel. To the extent that
any of the provisions of the applicable statutes,
regulations, or licensing requirement are
inconsistent with any of the provisions of this
clause, said statute, regulations, or requirement
shall prevail if it has a reasonable bearing upon
the applicant's fitness to be employed in any phase
of the program.
(2 )
The Municipality guarantees that no funds
under this Agreement shall be used to
religious training and/or services
individual receiving Purchased Services.
received
provide
to any
(3) No qualified handicapped person, as defined by
United states Department of Health and Human
services regulations, Title 45 Part 84.3 (J) and
(K) , which implements Section 504 of the
Rehabilitation Act of 1973, 29 U.S.C., 704, under
Executive Order No. 11914 (4 FR 17871, April 28,
1976) :
a. Shall be denied access to or opportunity to
participate in or receive benefits from any
service offered by the Municipality under the
terms and provisions of this Agreement, nor
b.
Shall any qualified handicapped person be
subject to discrimination in employment under
any program or activity related to the
services provided by the Municipality.
.
. 6
(4) It is the policy of Hennepin County that no
applicant or client shall be subjected to testing,
removed from normal and customary status, or
deprived of any rights, privileges, or freedoms
because of his or her AIDS status except for
clearly stated, specific, and compelling medical
and/or public health reasons.
(5) If during the term of this Agreement or any
extension thereof, it is discovered that the
Municipality is not in compliance with the
applicable regulations as aforesaid, or if the
Municipality engages in any discriminatory
practices as described above, the County, through
the Department, may cancel said Agreement as
provided by the cancellation clause of this
Agreement.
7 . MALTREATMENT OF MINORS REPORTING ACT, VULNERABLE ADULTS
REPORTING ACT
A. The Provider will comply with all of the provisions of:
.
(1) The Maltreatment of Minors Reporting Act, Minnesota
Statutes 1992, and Minnesota Rules, Chapter 9560,
Parts 0250-0300, as promulgated by the Minnesota
Department of Human Services implementing such Act
now in force or hereafter adopted.
(2) The Vulnerable Adults Reporting Act, Minnesota
statutes 1992, section 626.557, and all rules
promulgated by the Minnesota Department of Human
Services implementing such Act now in force or
hereafter adopted.
8. FAIR HEARING AND GRIEVANCE PROCEDURE
The Municipality will establish a system through which
recipients of service may present grievances about the
operation of the service programs, and the Municipality will
advise recipients of service of this right.
9.
INDEMNITY
.
The Municipality agrees to defend, indemnify, and hold the
county, its officers, and employees harmless from any
liability, claims, damages, costs, judgments, or expenses,
including reasonable attorney's fees, resulting directly or
indirectly from an act or omission of the Municipality, its
agents, employees, or contractors in the performance of the
e 7
services provided by this Agreement and against all loss by
reason of the failure of said Municipality fully to perform,
in any respect, all obligations under this Agreement.
The Municipality warrants that it has sufficient insurance
coverage to meet the Municipality liability requirement of
Minnesota statutes 466.02 and 466.04, and to comply with the
foregoing indemnification provisions.
10.
INDEPENDENT CONTRACTOR
e
It is agreed that nothing herein contained is intended or
should be construed in any manner as creating or establishing
the relationship of co-partners between the parties hereto or
as constituting the Municipality in any manner whatsoever.
The Municipality is to be and shall remain an independent
contractor with respect to all service performed under this
Agreement. The Municipality represents that it has, or will
secure at its own expense, all personnel required in
performing services under this Agreement. Any and all
personnel of the Municipality or other persons, while engaged
in the performance of any work or services required by the
Municipality under this Agreement shall have no contractual
relationship with the County and shall not be considered
employees of the County, and any and all claims that mayor
might arise under the Unemployment Compensation Act or the
Workers' Compensation Act of the state of Minnesota on behalf
of said personnel arising out of employment or alleged
employment including, without limitation, claims of
discrimination against the Municipality, its officers, agents,
contractors, or employees shall in no way be the
responsibility of the County; and Municipality shall defend,
indemnify, and hold the County its officers, agents, and
employees harmless from any pertinent tribunal, agency, board,
commission, or court. Such personnel or other persons shall
neither require nor be entitled to any compensation, rights,
or benefits, of any kind whatsoever from the County, including
without limitation, tenure rights, medical and hospital care,
sick and vacation leave, Workers' Compensation, Unemployment
Insurance, disability, severance pay and PERA.
11.
MERGER AND MODIFICATION
.
It is understood and agreed that the entire Agreement between
the parties is contained herein and that this Agreement
supersedes all oral agreements and negotiations between the
parties relating to the subject matter hereof. All items
referred to in this Agreement are incorporated or attached and
are deemed to be part of this Agreement.
Any material alterations, variations, modifications or waivers
of provisions of this Agreement shall only be valid when they
. 8
have been reduced to writing as an amendment to this Agreement
signed by the parties hereto.
12. SUBCONTRACTING AND ASSIGNMENTS
The municipality shall not assign, sublet, transfer, or pledge
this Agreement and/or the services to be performed hereunder,
whether in whole or in part, without the prior written
approval of the County.
13. NOTICE OF CANCELLATION
.
.
This Agreement may be terminated upon thirty (30) days;
written notice of either party.
. 9
Municipality, having signed this Agreement, and the Hennepin County
Board of Commissioners having duly approved this Agreement on
, 1993, and pursuant to such
approval and the proper County official having signed this
Agreement, the parties hereto agree to be bound by the provisions
herein set forth.
Approved as to legality,
form, and execution.
COUNTY OF HENNEPIN,
STATE OF MINNESOTA
By;
Chairman of Its County Board
.
Assistant County Attorney
Date:
And:
Associate county Administrator
ATTEST:
Deputy/Clerk of the County Board
Deputy Name of City
By:
Its Mayor
And:
Its City Manager
city organized under:
Plan A
Plan B
Charter_
.
HCA Form No. 104, Rev. 11/92
eXHU1IT A
. PrograTTl Title: Municjp~l Environmental H(:,~l[th S('rviC'E'~~ - Maintpnancl' of Existinq
Proqrams
Problems Addressed:
Problems addressed by this program include the prevention of food-borne illness;
maintenance of lodging and boarding care facilities; community sanitationj children's
camp sanitation; swimming pool sanitation and related activities performed by or
under the supervision of ful1 or part-time environmental health specialists~ pubUc
health sanitarians or other personnel approved by the Minnesota Department of
Health.
Goals:
1. Prevent food-borne illness, and contamination and decomposition of food
during production, processing, distribution~ storage, preparation and service.
2. Promote safe and sanitary environments in lodging and boarding care facilities
to prevent injuries and illnesses associate with such places.
3. Prevent transmission of acute and chronic disease agents by ensuring quality of
on-site drinking water supplies, and safe and sanitary disposal of on-site
wastewater.
4.
Prevent irritations, illnesses~ injuries and deaths associated with environmental
conditions of swimming pools and the community environment, children's
camps and other recreational facilities.
.
c.
-'.
Provide basic environrnental healtr, services consistent with the characteristics
of the geographic area and the population.
Objectives:
1. To ensure, in those municipalities with ful1-time personnel, the prov]slOn of
environmental health services consisting of routine inspe ction, complaint
investigation, licensing, plan review and laboratory testing services.
2. To ensure, in those municipalities with part-time personnel, the provision of
basic environmental health services; continue to examine unmet problems and
expanded programming to fill grlrS in services or resources.
3. To develop appropriate agreements with the Minnesota Department of Health
for delegation of authority to permit municipal responsibility for certain
licensing and inspectianal activities pursuant to Minnesota Statutes 145.55 or
145.918.
LJ, To continue the development and utilization of a County-wide information
system for environmental health services.
.
E.'\ h If', [ T E
0[11.":] TII...':,\ 5,' :::>J'L.~\,~ -\ 11'-\'.;: F OF R [:~~!r TI.'\C r c I,' .\ \S
.
REVENUES, GENERAL: ,..\ny e~~vi;cnrren,.:::J health 2.eti\'!1!, for which 2. permit,
IlLer,s l':: , or sir;liLr centroJ CIO vice is iequireG end for which a fee is peid, should be
inciG:tec. H;is ir.cluces fees :;-::,:>m ot:-.e: municipzl depar:;-r,encs for '.",hieh 2.n
envircnment2.l expencit'Jre Ie, c1almec: i.e.~ revenues from \\'2-ter bil1ing for
expendi cures cJ;::.lmec for chlorine, fluor-ine, or housing mainten2nce fees/permits
for ,he provision of he-using m2~nrenance inspections. Liquor lleense fees 2.re nor to
be includec. r\nv eTher revenue: i.e.. SFeC~2.1 6;C.n'L or sUDsid:;, shadd be repcrted In
this sec:ion.
EXPE..."\."'DITL"R..E.S;. GE..'\;L'-ZAL= Ii expendi:ures are c12.imed fer servicEs/c.ctivities
which are not conducted by reg'_d2.r e:-.\'::-cnmei,t2.1 neaJi:h pe:sonr,el (inclucin;
overhead and othe', common costs), then these cl2i;i1s must be s:..:;:,!='onec by:
2pproprictel~' cocumentec time GlsT,;aurion records:
2n 2ppro\"-2c ~r.i:orm syste:m :fer ~lccct.in6 indirec:
2nd used on 211 city prC'gr2ms; end
other doc..:men~c.tion on file .=nd UD-to-d.:=.te
2110C3.tion 02.sis used to cisuibLte C)sts to
2greement.
cOStS which lS 2.~plic:d
in s:.cpport cf
tlL,e progrc.m
2.11 other
'In C~:
this
Fer eX2rr.plet ":"'\n estimate 0: 10 perce;.t of 2. staff person's tlrne cevoted to 2-
prG~::2.m", is not e.il c.ccept2.0Ie allocation process.
.
PERSONNEL Pers.:::nnel not pro\'iG!r,g e. fuil-time equiveleiit wor~-< lO2.d in
environmer.t2~ ne2.1:h s:,oulG neve their wor~ c.lloc;:;.:ior. llstec on 2. sepc..i2.te pege in
2.cdi:icn L'O the dod2..r 2.mount listed in tr,e expenditure sectior,. Personnel suc:-, 25
housing inspeCTors, nuis2.nce ins?ectcr, City Clerk~ Cit)' \12n2.ger, etc., must ha.ve
E.deq'JE.te s~p~or: cc:curi',en:c :ic:-: proviced ~D cJ2.im enviror~me:lt2! ex~e:lCi~Ure5
(:~me re~cr-rs .:)r S::=':2StlCC=.J 2.L!'cC2L:!On).
FRINCE BENEFITS jncluc~ e!l:picye:-'s c::r;:::-~bL:t~or: LO P.E..R.,;., F.I.C..~,.,
~ospl :E.l~22. :icJ". :.n.-5~~2.rLCe~ liie irls~r~;-lce c.j~C \:..:or~~;ne;'~'s ccm~'er;s2. :icn.
OFFICE SUPPLIES II'.CLCe CGS<:S l!lC:.c:-:-e-::i :~r t~l",?;--,one, cu;::;l~G"..~icn Se,Ylce::.:,
pcs~2g~~ pi:f'iL:cd ~Q:-TTIS, 2.nG ....nlscelio.;i.eol!s e~-<~e:'tc2:.1e of:lce s:"':~'plie5.
PROFESSION:\L 5c..R V-;CES
l;l c~ L ce e x-:e:; d 1~'.Jre..':: f c. r IE.': C ~ E. :cr~/ 2.c:i vi :~E.S or
cc.r-J5i...!l:c..l.i\'e scrv~,::-=~ :-e:~2:. :ed 1:.J :he e;-~v:rcr.~:e:I~2.1 ht---=.~:~ pr:Jg: 2:-T:.
OPERATING SUPPLIES InclL!ce :::ie1d test equipiT,erlt, cr-:emic21s, thermometers,
s~rn?ling lTl2.teri~ls~ film 2..nd deve~~'ping cnc~ rrJ!sce122.n(:ous cFe!""2t2ng supplles.
EQUIPMENT REP AlR
Self-ex pl'::'Ji2. TO r:;.
MISCELL/I.NEOU5 Induce epxencitures :cr 2.tte:1d2.r,ce ci pr:J.fessicIi21 mee,;rlgs~
continuing eCl1C3 tion, cues and sub:scnptions, sool--;s 2.r.;:: public2 Lions.
CAPITAL OUTLA Y Induce m2jor e;qe:Jcj~L:re~ :or ec:;uipr:IE:::: 2nd f2.:::ilities.
SPACE RENTAL S,:,li-ex~ic:.n2,;::r:.
.
TRANSPOR T A TION !r.c~uGe cas: cf c~e:-c. ling 2.g':'i:C/ vehic~e(::) or reimburser;-;ent:
for the use of pe:scn2l 2UtO.
OTH[n
Ple2.se specify, in ceL::il, \\.'h2t t:-ie ex?e:lci::Jres ae fer.
E:\HWIT C'. ccntinuc.d
.
COI\\:-'IUi'iI--;--Y HE:\L TH 5ER VlCE.S Sl'~,L\\..:.S y OF REVE:'~I_'E p,:---;['\ E:\FE~iSE5
ENVIRCN\\E~T,""L HE:~,L TH FOR. THE PES-lOD
through
FOR THE CITY OF
E,'-:\F 0:\\~ ENT.-\L HEAL TH EXPENDITURES
FL LL .'\0:D P.....R T - T1:\\E El'-:VIRON~i ENT:\L HE.....L TH PRCGR:\\\S*
Bl'DGETED
Pe:sonr.e! Se:vices (Ful1--::ime pro~rC.ms only)
E.nv!~or:;;"ent2.J He2.lth*"'
C ler:c:.l SupportcC+
o Lher....-".
F:inse 2,="efits
Oiiice Supplies
Profession2.1 Services (including part-time environment2.l
heelt;, se:vices)
Ope:2."Li:lg SUl="plies
E~;Jir:TT,ert Repelr
~1 iscell2.:ieous
Cz.pit2.1 CUL~C.Y
.-c= :-)er-.-I
;.-rC .... I'\.. ., ~C_
T~c.n5?C :-:.=. riOr'l
O:he \~;e':::i:':..)
O!"r-:::.:='. 2:''';'/jF.O,'..;\\:::'';L\L EXPE\:DlTi_'P ES
Cr-Si::e Se';"2.se DispOSal P;ogrem
Cr.-s;-:e \'(,2.Le: Supply Progr2.m
.~\:-.~;:-;c1 C2r.::-:Jl
Noxious ';:"ee-:i Control
Housir.g nygiene
p',ir, W2.l:e:-, Noise Pollmion Control
.\knici;:J2.J ';"ccer Supply Chemic3.1s (Chlorine a.oa Flucrice only)
L2.!:::or2.~ory Support Services (well ,;vater, food, -::es;:i:lg)
C-":~":r (spec~iy)
TOTAL
,~"CTL' .2.L
..See Ex~ibit C for expl2.nc.tions.
.,,-On 2. sl.!ppi-=:mentary sheeT or en ~oti:om of pa;:;e, pJe2.se provide personnel bre2.kcown (1.e.; r.L.:rTlber 0-;
personnel end program area if appropriate),
EXHlelT 2:, continued
.VIFO:"" \ E<T"-'-.L HE:-\L Ti-i R E VENL'ES
REVU-:l:ES
Food L:ce:lse Fees
Food Venting \!2.c~ine Fees
S""immir,g Pool License Fees
Hctel/;\1ctel Lect;ing Fees
Permii:/Lice"se Fees :or O:l-Sjte Se'.\'2.,se Syscems 2nd \\'",ter Supplies
,;nim2.1 Control Fees or Service Ch<irges
,\ir 1\' c. ::er/:---':oisE PollL:tion Contrel Fees/Ch2rges
Service Cla::.;es for \\2ter Treatment Chemicals (Chlorine and Fh.!(')ride)*
Weec Com:-cl Fees or Se:-vice Chages
Pest Control Fees or Ch2rges
G2.r~c.ge 2.nc Refuse Haulers License Fees
r.cL:~;n8/Rer:El P:-operty Inspec:ion Fees
Ot;-;er Fees, Grants or SOL!rces of Reve:n..:e (specify)
(inclucinz C:-:S :funds ~rc\'iC:ec :,V Henne8in Count.....)
~ I J I ...
.cel 12.X
TOT ,::',1....
r--.... T--' - . --~ '-:
'_=-.-. jr;L.~.: .'_':,
BUDGETED
A.CH.!,..l,L
I certi:;' y :,~.c=. t ::0 the best oi rTI y know iecge 2.r.G be lief tha t :h e C2. ,2 repor:e c in Lhe c=.bo ve firlc=.r. ci 21 eXf".iji i:
is correct 2nd th2t all transactions we:-e mc.de in accorG2.nce with the :\greeme!lt provisions 2.~,d 2.ppl!c,,-::.l=::
2.ssur 2!lCeS_
,,;U1:.;"'IO:-l=~:::: C,iflCicl
r !5c~1 \1c.il2gemen: Gii~cer
Date
Dc. te
.+R_eVC:~1.2es for c~emjc",ls c;:.n be c12.imed LO the extent that the municip2.J \Vc.:e:- charges of:~set to::2.1 wc.t~r
pan:-;-;er,t ex?enclwres. It is 2.Ssumed to be 1 CO pe:-cent unless otherwise indic:te:::!.
.
.
.
EXHI BJT C
CHS Annual Report
- Face Sheet -
County ICity Name:
Authorized Agent.:
(::iJgnalure)
Date Signed:
'-",' -' .
. -.. ..'. ..
-, ",' ,..'
. .
., .
. " . ,- .
Offic~tiseOn1y;' .
. .... .,......' ::" "',":- ..": :.':..,....,.. .
.' ....... County /citj..NumbC.r:
(slxdigit number) ,
..,
,..
..
.
This form must be signed by the Chairperson. or Vice-Chairperson of the Community Health
Board, or an appointed agent.
.
.
.
n
-
'J]
;:::l
-
,.,
-
o
;;l:
:.i
z
C":
~
o
::::
~
CI:l
"T1
':l
3
-
n
:t
(J'J
(J'J
:.>
-.
;::1
::l
....
0.0
3
o
:;I
(1l
::Q
[T]
U'J
:>.>
::I
c..
~
,..,
c...
..., ~ ~ ~ :; .... .... :0
~ 8:: ~ ~ u. ~ ~ '0 ?" :--' a. ~ 7- '" !""" :-'
...,
> 0 0 0 0 0 ;' ;l Q .." "0 Z -- -l= ... 0 en (Jlr.'J m U >
c: ~ ...
:-' :T ~ :;. ~ :T .... ... :r -:r '.A c: -0 ,,'," " ;. ":I ~~ 'j' ... a.
... ... 5' ;J ... 5'. 03 n '" '" c:.. ::l .s. Vi " 3
... n n ... n' :5: ~ n :T:;l, ~
... .., .., .., .., a. '"0 '" '" -:::r n o>'a 0;
Vi' z :r: OJ 5' 3- ;::;"t'J'Q 3 (J'l - '"
C;; C;; Ui ,-. ,-. ~ a =:.:::\ ~.
(Jl (,11 - c: n " ..... m o' ~3 OJ Ul
";;l 1/ ~ ~ ~ ;;I OJ ;;r,"g OJ .. a. "0 "0 ~ 0; OJ
'" 0- " " c: ", __n ~
2. 2, 2. n n ;;' ;;; .. - "'c.. n "3, "''' ::;:
;:r ::r n ..- '<"
~ ~ .:;r .::<' ~ "" :::: .. '" =.~
< "0 "
~ ---- .. ~ .. (,11 z > ~. Vl
.. '" c: a: ... ..- (Jl
~ J n 0' ~ :;1'0 '"
~ " -- " '" '" ~
=::= -
::r
~ l
n-
o.
-
'-'
~ ~
=. n
it
n
n-
o.
~
n-
c..
':1
9 7'
;;.
'"
;J
-::.
n
Co.
Co
"
- ::;,
n- a
'"
c:.. 3
"
'"
n S
0
" -
OJ ;;
!:l 0>
n
Co.
-
.,
" ~
lO- ~.
..:r
9 -
'" ;;
~ =:.
n :T
;:;
c..
2 n
" '"
co. ::r
"":j
~ a
3
:'. ~
@ 15'
n '"
(;
lO-
::!1
n 0
lO- 3
"
Q "
'" 0>
@ ::r
,..,
~
;]
n _Z
l0- a ~
""0>
Q 0:=
? ~~
'"
:il 3 ~
C!. c..
::!
::r
....
en
?
ri
"
~
"T1
o
3
-
..-,
::J
;;;'
<-
:r.
,..,
:::J
<
r.
on
:.:>
::J
""'
--
':.r.
;:::
-
--
'-'
.
,-..
~ ,
-
~
-'
;:::
"7
...
'JJ
':J
~
'"'
.~
"
!J
e;.
:,::
...,
'i
'"'
':J
::J
-
.."
~
g
~
o
.
~
~
~
a.
o
:1
o
.
!""" ;r:l
~-B
" :1
Vl '"
'J
n-
o
;t;
~
.
~ !'l
9 0
.. 3
a. '"Q
;;. ':S..
o
cr
..
!:l
"
...
~I~
:; :t:
~ 0
c 1::
o _
F:l ~.
tu ~.
i.1~
~ 0
o
;:n'
o
'"
\I;
,..
~
3
o
:)
n
..
~
t.f1
a
-
p
...,
c
l
;:!
c
[.
-
-
<:
8.
"
o
to'
o
;.
o
...
~
Vl
1/
!:!.
~
-
."
~
o
;.
o
...
en
]
-;:
~
9
::r
n
...
..-..
Vl
~
!:!.
~
-
.....
c..
o
;.
o
...
Vl
11
...,
~
-
11"'
o
;.
o
...
,....
'Jl
11
n
~
..,."
!"""'Z
C g
:i ~
"6
:1
..
cr
n-
O
~.
"'
'"
o
.
~
~
'J
0'
'"
w
C
::J
""
~
...
!"
o
S-
o
...
~
1l
!:!,
3:
...
~
o
::r
n
...
..-..
c.tl
1l
!:!.
'3:
t
o
S-
o
...
en
11
!:!.
..:<'
.,..,.
~
9
::r
o
...
c;;
?l
!:!.
3:
...,
~
r"
Z
:l 0
o ...,
3 :::
-:I "
~ >'
::J ::;
V; ;;
--
z
<::
Q,
'"'
:.,
~
:;
~
'"'
~
"
~
Z
0::
'"
n
~
':J
....,
'-'
~
n
'"
~
"
2-
g.
n
.
z
.:)
:;'
;;:::l
n
w
"
a.
.... II
l'-
~..,.,...,:",.;,::.,:::..,:-..::::::
~.: :,' . . : , ~,". -' : -' ',." .'.' '.:.;.::
..,.... ,:"::" --:':,':' ,...-.... ,.',','
. .. . ..,' ..'.'.., ..
.. , .
::.' :.:.:.: ~:.: .7)'::.~ ~.::' :-:':' ....
. , " ',', ,.
..',.. ',',,' , '-.
..... .... .
. ,
::J
<:
n
~
""
::.
n
C.
...,
0"
::l
..,
3
n
a.
I"")
<:>
::J
3
n
c.
.'
.,
. ..
...
...
-~-l
~.~: 0
~;. n
a ~ 8
n n :J
::::J"'~
~-:; ~
. 0 n
~?c..
l ~2
...., 0 .....
ic..-<
.::..::;:;.~
n n
;::.. ~ ;.
- n n
~ '.Il ...
;. 'O.l ='
r'l'--""'''''<.
" ........
'" '"
:=--g ~
~ :! ;
-: ~-.<
~~~
~.~ ;:
~,~.~
~ :J
::'r.--
~ ~g
~ ~~
~ i~ ~
~ ~3
....c :2-
~=:~
;- ~ =
::."" -<
~ ~ D:
-::1"-
=- ;::;:'~.
"<. ;:::- =.
~ ~.~
.., <r,
- -
;:~.
E ::.
-..< S'
........::J
:2.;"
--==,:
. ~,
...
o
n
:>
::J
c:..
~
n
c..
....
~
"
g
::J
-.::..
~.
':"
-
~
',.,:,:'Li..
I':,:.:: .'.l.:. :,.:,. 'I.:' .:.:
..".1...'" .:....:..,':. .'.':..:.....'...
. ....,.,: '.. ." '. '._ ,n,:
: . ':'." ..'-"- ........... ,..
". ","", ". c
,I
,..1
..
"
IU'
""1'\
o
3
<
II>
.
--
"",
.....
;3
...
...
(";.
;::.
-
g
:::r
"7j
::>
~.
(';.
V>
n
-
-
'J;.
::::
~
-
...,
..."
tI
~
~
~
~
cr.
..-..
-
.."
'"
C!,
"
'"
~~
c. c.,;~
:.L~.
c..~'
i=1"(i'
-",
3' _'
" "
~>
.,.,
0"
~ "
?!.
"'"
"
.....
- .
" .
1;;;-
r, n
2.;.
"
\~~
:J
u:
"
.~~
(l~
':::'5'
<.n"
'"
:;::19
~3
n""::l
<.~
... -,
a."
t;;'
'""'
......0-
::r'3
...,"0
0-
c ..
~ 5'
~;;;
",-
'" '"
;l;i
n '"
=...iQ"
o '"
OJ -
"
c..
r.l
::>
>0'
,.., ~
-,..,
'5'n
'" 3
'" n
::>
'"
~,~
" "'
" "
j-1 '^
a.
a .. .."
:... ~ ~
_ _ t..
n -. I
9-. ~ ~
.: ,-
:l ~ ~
"'" ; :.
c:.,-. . ('\
'" .
>:
!"
a .. 1.....1
. . 8. "
[ ~ 5' ~
__~ =:r ~ l
c:: .
3 C' C'
'" '"
:;r:l"" "'"
iii'. .
":
-
I..""..,'.'"
. , "."C ,.
. . ~ .-.
........... '................. .....:...........:
,-, "', - ".'.,
," " L ._:", .'~" '
.' .' ",'".
'.." ,.... ,",'.".,
: ' <:~: :', : - :~'~", '.: ~:'.::::
.: .:.:'.:::..1
"',','-. ...., :.",:'"',-
";" ~:, - .' =;::,:. }.:':"c.
..' ...... '.' ','
" " _, : /",'1
'"., "-',
"
~
'"
i;;'
~
'^ ... .....
(j ./
~ :t -
Z ~ ~
0. '
O ..., ..,.
n _
n=,O
i:u 'JI- 3
::> "
;" Q "'J
0. 3 "'
8 ~ ?-;
..... . .
:> '"
-. 0
;. ~
~ ~
3
-:l
>
...,
n
"'
'"
,.
...,}"" .,.,.\
,.n.,..,.........
.:; " :-" - ~.:.
"', '........
t
!"
t"""
;:;.
o
:>
1>
a.
.
~
'Z
o
::>
r-
;:;-
o
::>
Yi
0.
?'
~
c
o'
=>
'"
.
?:J :-&
s: -i
n~ n
= 3
~ ~
n -:1
m .."
::> '"
~ n
o =-
M :0'
n 0"
3 "'.
o
'"
.
."
!" 'Z
o
r'" ::>
~. Q
~ ;3
a. ;3
. c
::>
~.
"'ll
"
2:
;:;'
~
'"
g
Ul
C
"t:I
-g"
0'
"'.
,..,~.,
..~.:. ::c_::_ ...,: ':
..:-:...:......"
--:-....:.-,.;'.....
:.:.:.,.:.:.,.....
.-:._-.:;:::..,....
......:.:.~., .:;.
::')::=::':~.: ::;:;~:
::-:;:.:;.::..:...
:.,.-::- -',.:.-.
.:.':.;.:. :'..-'.-'
...::..... '.':.::.
\",",,1
.~.:' .~.:.: ..: ;:.:.~.
.'.',: ':.: : -~ ;'.;:.:,.: :
./~;~.'::.::.~
?"
Z
o
::>
r--
;:;'
o
::>
'"
...
0-
.
- -
~ 9
~ U>
~ l
~. ;3
n :i"
0. .,..
~ "'tI
:. 8
a. -
'"
~
'"
'"
;:;
~
::>
0-
2
'"
-
!"
...,
...
)>
';I
::>
e:
~ ~ ~ ~ ~ f: ~
00000 ~ ~
;. ;. ;. ;. ~ ~ ~
~ ~ g ~ ~ < a
Vi~U;C;;{j} g 5
~~1]13-~
~.~~~~(rQ ~
........." -.-r ---- ...J "-' "7 --
.. ". .. .. .. ...... 0-
'"
n
"'"
:;'
n
'"
d
-l
>-
r:
.
.
?'''Tl-l
- 'TJ';l 0
~ '" 15.
~~l~
:? =: '7?"
-,l], :i Yi
~;;'OI1:1.
c "" 0
c:..>(I:=
n~ 1>>--<
;5::> ~~
::~....;r
~ ~ 2. ::l
?~~.;.-
.., Vi"';:! n
= ~t1Q Q)
':;' ~ i:rl~
';7 _. ::1
75.g .Q
- .-
n U'J c.'-=r
~.g~ ~
:; c ..... ~
:::";;::OQ.
":J '0"'.... ~
:s: ('I._n
'-~
;;::l-::r~~.
:;';"'11. 0
7;"""" ;::]
-:r:..J :ll:l
~3 "3
!.": n ii
;;'::J n
~" 3
::"3 0
..1'1 ~ ::I
-,,, -
=>: ~,
:3-y. ;.
no "7
'3 ~ =
-- 0".;
~ 0 _
-'" -
'"
;. 0
II> c..
P 0
~ ~
<> ...
n =>
-" !on
=: ;;
ri' QQ
'" '"
- ::>
::> 0..
~ 5'
n '"
;; ~
c. :l
0" o'
'< ::>
n ll>
- ....
Vi =.
. ~-
n'
!"
.."
n
'"
'"
"
::>
S!-
n
~
'"
(l
'"8
:l
::>
""
~
"
""
=-
~
"
Cl.
~.
~
~
C'
'"
...
a"
;:I
'"
.,e:-
o
So.
'"
c
::>
0-
n
...
. .
. .
.
.
"'T1
o
...,
3
<
r:T
m
~
....
..>.
...,
::l
~
3
n
~
'"
::t
n
::...
::r
)>
0-
~:
('>
'"
>
~
..J,
~
~
'"tl
c:
~
i'i'
;;-
01
;.
'Z
!:'"
:!:
"
n
n
n
o
"
Q.
;"'"
<
n
~
o
....
n
o
~
9.
~ ~
"'tl ::::
:J, 0
~ ~
n ~.
""
~ n
~ 2..
~ n
Z
n
l;
N
>='
"'tl
::I,
~
n
W
~
""
n
'"
';5,
3 \P
III ~.
Q1 'Zl~
_, n
~, l;
"
""
tv
;l>
"
3'
..
........
31
i
n
o
"
9.
tv
!'"
:E
~
;;
.....
OJ
c
n
;;I
d ~ !! ~ ~ ~
-:I . . ' . '
:> 000 0 0
t"" - - - - -
:::r -::r =r ::::r =r
n n n n .....
to;, .... ... .., ""'"
-.-"-".---
U') Vl (fJ 'JJ c.n
"'X X X X X
nnnn""
~~~~~
'-:-:' ':-:' '":-':'" "7-:" ~
......-
-== Di"
::1. ~.
'" -
CI. :=.:
n '"
-",
3' _,
:> "
~>
""
on
-,,,
,....
:::..r~.
" '"
n
v.>
.'...,.....
._._._......' ......,.,...c
;:~~t\~ ~\r;\: L/L,
. ........'.....'..'.... '.'..'.'............. c~.
{\~r ~\:(~~: :~r:~(
:.:. :.:.... ",". ". :-: . ~: ~::~ ."
'"',n," ....n,. - ,-',-,'
c....... ,.'., "-'," ,
.., c _ ,_ ,.
,-.",--,'," ,.....:..
..
~
..
.
:-J
-
U;
::z:
l"'l
""=
o
;::r::
~
Z
:'l
~
....
"-'
::c
:s:
'J.J
~J
1~
(; (;
c..'"
'I
;~;.- 1
,.
1
,....!
...
;.,;,,;,
::>
':7"",
""'x
~~
=5'
~~
:;00
g 3
".."
<'~
n -.
c..~
'"
.c:
;::3
;:\~
- 01
c: _,
'JQ"
:T -
'"
::> -
'J' :>
~ .~
~:c.
-~.
o ..
" ~
n
0..
,..
=>
>3'
n ~
-n
-'n
=5 3
"' n
?
.
:::0
n
.s.~
n OJ
9 "
n '"
Cl.
T/I ::~. .}..:' :.....'..1".1.::.': , .
...,..... .. '.. _.....-,.,. "', .. .
':,:;:':"i:",,::,:,','...}:::.'
:\::', \>: :,::.,~.~ -.,:. -:: ,:.". . '.
::. \= " .~ ~ ,:: . '-': -' .~ - ::
. -.: ... ..0 ., ~. ._. _ .
.... . .
~ ~ : .'-. .' .
n
-
-
r;r.
:=:
~
"e
o
::c
:j
z
C')
~
c
~
::
r;r.
'"f'l
o
8
:5
'"f'l
o
::>
0-
O:l
n
<:
n
..,
to;
~
rn
~
~
~.
::r
:3
n
2-
-
::l
v>
n
:l.
::>
~
';/)
n
::>
..,
n
v>
?' ~ ~ !--' !" ~ :;
'"
-l ~ ~ ~ ~ ~ ~
~ ~
-.:0 ;2l ci'
8 :>
8
tl
.
z
c:
3
<:1'
n
...
0
...
[
Ir-
;;;
~
Vi '
:::r
3
n
:=.
:;
'"
X
::l
0'
:>
'"
:
z
c:
3
<:1'
n
...
2-
~
O<l
5'
O<l
Ir-
;;;
~
C;;"
::r
3
n
:=.
:;
'"
X
::l
o'
"
'"
.
.
V'J V'J
::r ::r
o 0
c: c:
E: E:
n n
.0 .0
c: c:
~ ~
So 5-
n n
o 0
~ ~
~ ~
rn rn
" :>
S. s.
a a
" :>
3 3
n n
:> :>
~ ~
::t ::t
n n
e. ~_
5- 5-
6l 6l
3 3
< <
! .F
g g
i: c
3 3
:> :>
'Ow ...w
t"'" t"'"
:i" 5'
n n
!'> ~
ci1
..,
8
:S
:-:'
"'0
..,
<'
po
0-
~
~
~
tl>
0-
..,
po
v>
'""d
(1l
..,
0'
..,
3
(1l
0-
cr"
::r-
(1)
n
:I:
Vl
>
(1)
::l
n
~
3
-0
n
:;
0'
3
~
0"
:>
z
p
2-
en
'"
3
"0
0'
"'.
"':l
o
~.
<'
n
~
3
-0
0'
'"
.
.
V'J
'"
3
-0
0'
'"
R'
,.,
n
s:
:>
(IQ
Q:
~
c:
-0
g
"
;;;
::l
~
~
;I
g:'
,.,
n
:I.
'"
<:1' !"
lC' ~
3 3
-0 -0
n n
'" '"
Iv Iv
.... ....
o
3 ~
~ -;::;
....
'"
::>
Q.
^
o
3
O<l
.......
!"
z;
~
n
~
a
O<l
n
"
.
.
... ...
;. ;.
n n
tl tl
tn" iii'
.. ..
::> :>
n n
:> :>
~ ~
c: c:
:> :>
Q. Q.
n n
... ...
;. ;.
n n
-c Z
g, 9
=. 0
~ ...
~ ~
3 ~
-0 -
_ n
n '"
'" .
i Q.
_ c:
c: 3
3 :>
? -
_ ::r
:::r n
n ...
... n
n
3 ~
c: '"
'" -
- <:1'
<:1' n
n
'"
..
::> N
n
n .,
:> 0
~ g
c: ::I
:> 0
C. :>
n .
... N
n
;. a
n
n
. ::>
g; -
3 ~
"0 c:
- ::>
~ c.
n
:;.;l ...
n -
,., ::r
n n
<'
S' .,;
O<l 0
'"
...,., ;:::
o _.
= ;;
o
:E V'J
, '"
c: 3
"0 "0
g if
:> .
;;; 8
,., -
- c:
. 3
8 ?
;:
3
::>
.
GENERAL INSTRUCTIONS FOR CHS REPORTING
One original and two copies of the completed forms must be submitted by April 1, 1989, to the
Minncsoca Department of Health District Office. For assistance in completing the forms, contact your
District Representative. One set of these documents v.i.I1 be retained in the District Offices. District
Representatives will forward the original report and one copy to MDH.
COU1\'TY AND ClTI' REPORTING
A separate reporting form must be completed for each county or cit)' participating in the CHS program.
Each report should include data on all reportable activities that are mcluded in the CHS plan and
budgel.
Reportable actj,i.ties include those which were funded by the local agency through the use of CHS
subsidy, local funds, special projects grants, and other state and federal funds. If one CHS agency
contracts for services with another CHS agency, the agency that funds the services should report the
related activities. Addilionally, information may also be requested of those agencies participating in a
special project grant.
REPORTING ACTMTIES AND EXPENDITURES BY PROGRAM CATEGORY
The CHS Reporting forms are organized around the CHS program categories:
.
. Disease Prevention and Control
. Emergency Medic.aJ Care
. Environmenlal Health
. Familv HealLh
. Health Promotion
. Home Health Care
. Not Allocated to Program
This is done to improve the compalability of the CHS plan, budget., aCtiVIty report and expenditure
report. This compatability is intended to simplify the analysis and interpretalion of the data at a
district and slate level. For clarification as to which program category subsumes which actIvities, see
Appendix I of the CHS Planning and Reporting Manual.
VOLlf1'.o'TARY NARR.\.TIVE REPORTS
Any additional information lhat CHS agencies would like lO provide in the way of narralive reports is
welcome, Such reports might include local annual repons, reports on local evaluation projects, or other
special reporls regarding community health services. If provided, these reports should be in addition to
and distinct from the required forms. This is necessary to avoid confusion as to what data should be
keypunched and processed as a parl of the roulinely reported data.
GEl\TR-\L DEFINITIONS
Disease Prevention and Control: "Disease prevenlion and control" means activilies intended to prevent
or control communicable diseases; these acll\i.lies include the coordination or provision of disease
surveillance, investigalion, reporting, and relatcd counseling, education, scrcening, immunization, case.
m anagcmenl and clinical services.
.
Emergency Medical Care: "Emergency medical care" means activities intended to protect the health of
persons suffering a medical emergency and to ensure rapid and effective emer~ency medical treatmenl;
these activities include the coordination or provision of training, cooperalion WIth public safety agencies,
communicalions, life-supporl lransporlation as defined according to section 144.804, public information
and involvement, and syslem management.
Environmental Heallh: "Environmental health" means acllVIlIes intended to achieve an environment
conducive to human health, comfort, safety and well-being; these activilies include the coordination or
prmi.sion of education, regulation, and consultation related to food protection, hazardous substances and
product safely, water supply sanitation, waste disposal, environmental pollution control, occupational
health and safety, public hcahh nuisance control, instilutional sanitalion, recrealional sanitation including
swimming pool sanitation and safety, and housing code enforcement for heallh and safety purposes.
Reporting and Evaluation
49
FORM I. CHS STAFFING BY PROGRAM
. INSTRUCTIONS:
Enter the number of FULL-TIME EQUIVALENT (FTE) staff persons for each of the occupation titles
by prog;ram category. The number of FfE employees who worked directly for the CHS agency,
regardless of source of funding, are entered in the "Positions Filled" column. The number of FTE
positions provided by contractors are entered in the 'Positions Contracted" column. Entcr any unlisted
occupation in the 'Other" categories and specify the position title in the space providcd.
The occupation categories listed on this form are intended to represent a staff person's job title. For
example, the full value of a Public Health Nursc's FIE should be reportcd on line # 12, "Public HealLh
Nurse." This FIE may, however, be allocated to morc than ODe CHS program (i.e., .5 FTE Family
Health and .5 FfE Health Promotion).
ITE Slandards
Some counties use differenl standards for calculating full-time equivalent (ITE) employees. One
general defmilian is a 4()-hour week or 2,080 hours/year as 1 FTE; a vanation in some counties is 37.5
hours/week or 1,950 hours/year. Please state your county's defmition of FTE in hours per week on
the blank provided under the title "CHS Staffing by Program." Then use your county's FTE standard
to calculate the FrE's to be reported in each occupation by program category.
For contracted positions use the actual FfE figures from billings or end-of-year reports from
contractors. Estimate tbe FfE for flat fee contracted positions such as a medical consultant. Roster
nurses are considered contracted positions.
In-Kind Starr Effort
Several CHS agencies monitor the FTE of in-kind staff effort and include the value of this effort in
their CHS budget and expenditure report. If your agency monitors in-kind staff effort, report ic aD line
15.
.
NOTE: All FTEs should be rounded to the nearest hundredth (x.xx). If any of the FfEs total more
than zero, but less than .01, report as .01.
D EFINITI ONS:
Administrative Starr: Individuals, such as an Accountant/Financial Manager, a CHS Administrator,
clerical support staff, as well as program directors and supervisory scafL This occupation category
would also include the following job titles:
.
Account Clerk
Administrative Assistant
Administrative Manager
Administrator of Nursing
Assistant Biostatistician
Assistant Director Public H calth Nursing
Bookkeeper
Business Office Staff
Clinic Director (general)
Clinic Manager (general)
Community Health Semces Supervisor
County Health Dept. Administrator
Custodian jMaintenance
Data Processing Officer
Deljvery Worker
Director of Planning & Administralion
Driver
Graphic Artist
H calth Coordinator
Health Planner
Health Pro!p"am Analyst
Health Stallstician
Janitor
Marketing Coordinator
Media Specialist
Medicare Consultant
Medical Records Practitioner
Nurse Prowarn Manager
Nursing Director
Nursing Supervisor
Office Manager
Other Administration
Planner
Public Health Nurse Supervisor
Program Administration (general)
Program Development/Evaluation
Specialist
ProW am Planners (general)
Pro~ect Assistant
Project Director
Public Information Specialist
Records Specialist
Supervisor Administrative
Services
Supervisor Public Health Services
Supply Manager
Storekeeper
Reporting and Evaluation
S1
. ~ a physican for the CHS agency should be recorded here.
PubliC' Health Nurse: A nurse registcred in State of Minnesota and certified as a Public HealLh Nurse.
.
Other Nursing Staff: This occupational category includes Registered Nurses and Licensed Practical
Nurses as well as other positions which directly assist nursing activities, and are not certified as Public
Health Nurses. Other job titles for this occupational category would include:
Asst. Coord, Maternal and Child Health
Child Development Coordinator
Child Health Aide
Development Services Specialist
Dial Aides for PSg
EPg Coordinator
EPS Outreach Worker
EPS Technician
Famil.y Plannin~ Personnel
HospIce Coordmator
MCH Consultant
Manager Maternal and Child Health
Nurse Midwife
Nursing Practitioner
Nursing Consultant
PNA
Respite Care Coordinator
School/Community Health Aide
School Health Aide
Youtb Intake Worker
Therapist: Any of the following types of professional workers:
. Physical Therapist: A professional worker prepared to evaluate clients' neuromuscular and
functional ability and to initiate a treatment plan, in conference ",,'itb a physician (see 42 CFR
(Code of Federal Regulations) 405.1201 (i) for required credentials).
. Occupational Therapist: A professional worker prepared to help clients develop and maintain
tasks essential to daily living (see 42 CFR 405.1212 (g) for required credentials).
. Speech Therapist: A professional worker prepared to treat clients who have a communication
problem relating to speech., language, or hearmg (see 42 CFR 405.1202 (u) for required
credentials) .
In-Kind: Several agencies monitor the FfE of in-kind staff effort and include the value of this effort
in their CHS Budget/Expenditure report. If your agency monitors in-kind staff effort, report it on line
15.
.
Otber: Any occupation title which cannot be included in the categories lisled above. Please try to
include everything possible in the listed categories and specify .other" entries.
.
Reporting and Evaluation
53
.
.
.
or chemical poisonin~. For purposes of this rcport, a single case of reactivated tuberculosis which has
Dot resulted m additiOnal infections should not be considered an outbreak. Indicate in this column only
those confirmed outbreaks in which the agency was tbe lead or principal investigator.
Probable Foodborne/Walerborne Outbreaks: A probable foodborne or waterborne disease outbreak 15
derlDed as an incident in which: 1) two or more persons experience a similar illness, usually
gastrointestinal, after ingestion of a common food or water product, and 2) data are insuffiCIent for
epidemiologic analysis; however, a specific food or waler item is suspected.
Non-Related Outbreaks: Nonfood or nonwaler ingestion-associated outbreaks are deflDed as two or
more cases of illness related by time and rlace in which an epidemiologic investigation is conducted and
the results are inconclusive or do Dot implicate food or water as a source of the outbreak.
Reporting and Evaluation
55
.
.
.
FORM V. ENVIRONMENTAL HEALTH ACTIVITIES
INSTRUCfIONS;
This form should be completed only for those actl\111es which arc supported by the agency. Enter the
numbers requesled by the column headings for each of the types of facilities and activities listed for the
past year, Lines 1, 2, 3, 4, 5, 6, 7, 8, and 9 should be reported only by agencies with authority to
license and inspect under delegation agreement with MDH.
DEFINITIONS:
'l'--pes or Em'ironmental Health Activities
Facilities in AgenC)"'s Jurisdiction: Exact count, if known, of the facilities in the Agency's jurisdiction,
including zero if none exist. Lines 1, 2, 3, 4, 6, 7, 8, and 9 should be reported only by agencies with
authority to license, inspect or permit under delegation agreements with MDH. For # 1, 2, 3, 4, 6, and
7 use the number of licenses issued. If uncertain, write unknown or give a range, e.g., less than 25.
Inspections covering compliance with the Minnesota Clean Indoor Air Act (MClAA) must be recorded
on line 5. Facilities are in agency's jurisdiction only when a delegation agreement with MDH exists.
"facilities Inspected by CHS: column 2, should be the same number or less than "Inspections by CHS;
column 3.
Facilities Inspected: The number of different individual facilities which were inspected, according to the
definition specified below.
Inspections: For items # 1 - #9, inspection means a complete full-scale planned inspection. Il does
not mean short follow-up inspections, e.g., to determine whether freezer temperature is now low
enough, or if NO SMOKING signs are properly posted.
For items # 19, #20, and #21 both systematic and scheduled inspections, e.g., appropriate housing
maintenance inspections, well or septic tank construction, and non-routine inspectIOns should be added
tpgether.
The difference between "new" and "existing" is made as follows: A system or well 15 new if it has
never been put to significant use; otherwise it is an existing system.
In every case, there should be at lc.ast one inspection for each "facility inspected."
Complaints Received: Any communication concerning any of the activities or facilities listed in the left
hand column. "Received" docs not distinguish frivolous from sincere, nor does it include resolution.
Complaints Investigated Through an Inspection: The number of complaints which resulted in an on-
site visit, no matter how brief. Do nol enter the number of on-site inspections. The number of
complaints investigaled through an inspection is unlikely 10 be larger tha.n the number entered under
"complaints received."
Enforcement Action: Any method (in v,Titing) undertaken after issuance of an inspection report and
correction orders used to insure compliance, including letter of non-compliance, license revocation or
suspension, administrative hearing, fine, violation tag, or court aclion. It does not include field
investigation where none of the foregoing action is taken. This same criterion would apply to
enforcement actions relative to the MClAA..
Facility Plans Reviewed: Those reviewed pursuant to a state law or rule, or a local ordinance.
F<lciJities
FaciIi t)': Defined by the types of establishments listed. Each of the establishments listed (i,e., lodging
establishment, a swimming pool, ete.) is a facility.
food-Beverage Establishment: As governed by Minn. Stat. 157 (1986) and Minn. Rule, parIs 4625.2400-
4625,5000 includes a restaurant, a bar, or a restaurant/bar combination.
NOTE: Vending machine inspections arc reported below On line # 14.
Reporting and Evaluation
59
.
.
.
Private' ~llge System: Consider private sewage systems as those systems defined in Minn. Rule, parts
7080.0010-7080,0240, whether or not the standards have been adopted by reference by the county, and
whether or not the systems meet those standards.
Animal and Fowl- Control: Activities undertaken to eliminate unsafe or disease enhancing conditions
caused by animals and/or fowl and violations of a local animal control ordinance. Examples are animal
bite investigations; improper waste disposal; and keeping of any animal, fowl, or reptile where prohibited
by ordinance of any municipality or county or without a special pennit. Do not include animal
impounding activities or pet leashing enforcement.
Waste Hauler (solid): As regulated under Minn. Rule 7035.0800.
Other: Any activity which does not fit into a previous' category. Specify the type of activity. Please
try to include everything possible in the listed categories and specify .other" entries.
NOTE: A CHS agency may want to describe in a short narrative form any environmental health (CHS
supportable) activity which the agency deems as being worthy of reporting, i.e., it consumes more than
1 % of its resources or approximately three days' worth of work during one year's time, or it is an
activity which is expected to require significantly more of the agency's resources in succeeding years.
Any reporting done under this beading is purely optional.
Reporting and Evaluation
61
. FORM VII. PRIVATE WELL WATER QUALITY
INSTRUCflONS:
Enter.
1.
the number of private well water samples analyzed for coliform bacteria and for citrate
nitrogen,
2.
the number of samples contammg coliform bacteria and the number containing tbe specified
levels of nitrate nitrogen,
the number of positive samples for coliform bacteria and for the specified levels of nitrate
nitrogen which received follow-up contact.
3,
What to Include
. The number of samples should include original and repeat samples from private domestic or
commercial wells, food processing plants, schools, licensed establishments, etc.
. If a sample contained both coliform and nitrate nitrogen, it should be counted in both
categories.
"'hat to Exclude
.
Do nol include public community water supply samples.
The samples reported as containing 10 mg/l or more (>) of nitrate nitro~en should Dot be
included in the counts for 1 mg!l or more (>) and less than (<) 10 mg/l nitrate nitrogen.
.
.
DEFINITIONS:
Samples Containing Coliform Bacteria: A positive sample which contains one Or more bacteria.
Samples Containing Nitrate Nitrogen: A positive sample which contains at least one milligram of
nitrate nitrogen per liter of water,
Follow-Up: Action specific to a particular sample result. It does not include routine attachment of a
leller or information brochure to a lab report which helps in interpretation of results or tells how to
di5infcct a well.
Addendum for Environmental Health Data
Pcrhap5 the best way to explain the proper recording of environmental beahh information in the CHS
Report is through answers (A) to a number of questions (0) which have arisen or may arise.
1 0: Ullen a person representing an agency has been subpoenaed and appears in court, how is the
alti~'ity recorded?
A: Only court appearances that result from enforcement action taken by the health agency should
be reported. Form V, column 6 would be used. Appearances for any other purpose would
not be reported.
2aQ: How does one report the time spent making a site visit for purposes of discussing emrfronmental
health matfers such as remodeling a licensed facility or bu.ilding a facility that will be licensed?
A: An account of this type of activity is not requested.
2bO:
If a person representing an organization without an appointment came 10 an environmental health
agency and discussed requirements for remodeling a licensed jaciliry. how would the activity be
recorded?
.
A:
An account of this type of activity IS not requested.
Reporting and Evaluation
63
.
.
.
7 Q:
8 Q:
9 Q:
lOQ:
11Q:
A:
A:
Should counties with delegation a[J'Ccrnents for non-community public watcr supplies repon tlreir
non-<:ommunity public water supply actil'ilies on line #9 "Non-Communi~~' Public Waler Supplies"
lJ.!J.11 line #8 "We/J Code Enforcement"?
Yes, The Well Code Enforcement program includes non-community public water supplies.
Line. #9 gives MDH the information it needs that is unique to licensed and non-licensed non-
community public water supplies,
A:
If a CHS agency docs laboratory water ana(~'sis for other counties or other CHS agencies, who
should be responsible for reponing the number of samples ana~yzed in Form VI/?
Information should be reported by the agency having jurisdiction where the water sample was
coUected, irrespective of where the analysis takes place.
Arc inspection scorcs for limited food and beverage facilities to be rccorded in Form VI? Arc
limited food and beveragc facility activities to be recorded in Form V.
A:
Yes, the information is to be included in both forms.
A:
Form V. linc 10, refcrs to swimming pools. The definition of swimming pools is pools regulated
under Minn. Rule, parts 4717.01fXJ-4717.3900, which means all public pools, Some environmental
health agencies are also inmlved with private pools. Should this work be recorded in Form V?
No, on line 10, only record s\l.lmming pool activities tbat involve public pools (those serving
many people, e.g., school, municipa~ apartment building, townhouse, etc.).
How are services provided to agn'business (0 be recorded?
If a routine inspection is made of the hog farm because a feedlot permit has been issued, and
if time is spent discussing surface and ground water protection options, then the whole activiry
should be reported on line 24 of Form V under the heading "Inspections by CHS:
When an investigation is made at the hog farm as a result of a complaint or inquiry
coocernin~ possible surface and ground water pollution, then the activity would again be
reported III Form V under the heading "Complaints Investigated Through Inspectron." The
activity would be reported on line 24 and the word "feedlot" would be added if the agency
issues permits. Line 16 would be used if no permits are issued.
Reponing and Evaluation
65