PSA with Institute for Chilld and Family Health, Inc. 01 ((- obn10
• PROFESSIONAL SERVICES AGREEMENT
BETWEEN THE CITY OF MIAMI BEACH
AND
INSTITUTE FOR CHILD AND FAMILY HEALTH, INC.
FOR
CHILD AND FAMILY SERVICES, PURSUANT TO
THE CITY'S SERVICE PARTNERSHIP INITIATIVE
This Professional Services Agreement ("Agreement") is hereby entered into this 1st day of
August 2015, between the CITY OF MIAMI BEACH, FLORIDA, a municipal corporation
organized and existing under the laws of the State of Florida, having its principal offices at
1.700 Convention Center Drive, Miami Beach, Florida, 33139 ("City"), and INSTITUTE FOR
CHILD AND FAMILY HEALTH, INC., a non-profit Florida corporation, whose address is
15490 NW 7th Avenue, Miami, Florida 33169 ("Contractor").
SECTION 1
DEFINITIONS
Agreement: This Agreement between the City and Contractor, including any
i exhibits and amendments thereto.
City Manager: The chief administrative officer of the City.
Contractor: For the purposes of this Agreement, Contractor shall be deemed to be
an independent contractor, and not an agent or employee of the City.
Services: All services, work and actions by the Contractor performed or •
undertaken pursuant to the Agreement.
Fee: Amount paid to the Contractor as compensation for Services.
Risk Manager: The Risk Manager of the City, with offices at 1700 Convention Center
Drive, Third Floor, Miami Beach, Florida 33139; telephone number
(305) 673-7000, Ext. 6435; and fax number (305) 673-7023.
SECTION 2
SCOPE OF WORK (SERVICES)
2.1 In consideration of the Fee to be paid to Contractor by the City, Contractor shall
provide Functional Family Therapy services for up to twenty-five (25) children and their
families, as further described in Exhibit "A" hereto (the "Services").
2.2 Contractor's Services, and any deliverables incident thereto, shall be completed in
accordance with the timeline and/or schedule in Exhibit "A," entitled "Scope of Services."
2.3 Contractor agrees to be bound by and shall fully comply with the terms of the
Agreement, dated October 14, 2015, between the Children's Trust and the City of Miami
Beach, for place-based/countywide community partnerships (the "Children's Trust Grant
Agreement"), which is incorporated herein and attached hereto as Exhibit C.
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SECTION 3
TERM
The term of this Agreement ("Term") shall commence upon execution of this Agreement by
all parties hereto, and shall terminate on July 31, 2016. All Services to be rendered shall be
completed no later than July 31, 2016.
Notwithstanding the Term provided herein, Contractor shall adhere to any specific timelines,
schedules, dates, and/or performance milestones for completion and delivery of the
Services, as same is/are set forth in the timeline and/or schedule referenced in Exhibit A
hereto.
SECTION 4
FEE
4.1 In consideration of the Services to be provided, Contractor shall be compensated on
a fixed fee basis, in a total amount not to exceed Fifty Thousand Dollars ($50,000.00).
4.2 Contractor shall be compensated for the Services, as set forth in Section 2 and
Exhibit."A", as follows:
Contractor shall not be compensated for any services performed before the
commencement of or after the termination of the Term of this Agreement.
The City assumes no obligation to provide financial support of any type in excess of
the total Fee set forth herein. Contractor shall not invoice the City for any services for
which Contractor has invoiced another funding agency. Similarly, the City shall not
compensate Contractor for any services that have been funded by another funding
agency.
Contractor's compensation shall be further subject to and conditioned upon all or any portion
of the Services to be provided herein being allowable and within the Scope of Services
delineated in Exhibit "A".
4.3 Contractor shall provide the City with a detailed invoice, no later than the third (3rd)
day of each month, that details all services performed by Contractor in the preceding month.
Contractor's invoices shall include payroll records and other applicable backup
documentation. Contractor's invoices are subject to the review and approval of the City
Manager and/or his or her designee, who shall be the Department Director of the Office of
Housing and Community Services. The City shall not remit any payments to Contractor
unless Contractor provides the City with a detailed invoice that is acceptable to the City.
4.4 INVOICING
Upon receipt of an acceptable and approved invoice, payment(s) shall be made within thirty
(30) days for that portion (or those portions) of the Services satisfactorily rendered (and
referenced in the particular invoice).
Contractor shall submit monthly Reimbursement Requests, Monthly Service Summary
Reports, and accompanying Monthly Client Status Lists, as set forth in Exhibit "B", which
include an itemized, detailed description of the Services, or portions thereof, provided
(including the names of the clients served and dates of service provision) and cost(s) for
same.
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Invoices shall be signed by an authorized employee of the Contractor, shall include a
detailed description of the Services (or portions thereof) provided, and shall be submitted to
the City at the following address:
Maria Ruiz, Department Director
Office of Housing and Community Services
1700 Convention Center Drive
Miami Beach, Florida, 33139
SECTION 5
TERMINATION
5.1 TERMINATION FOR CAUSE
If the Contractor shall fail to fulfill in a timely manner, or otherwise violates, any of the
covenants, agreements, or stipulations material to this Agreement, the City, through
its City Manager, shall thereupon have the right to terminate this Agreement for
cause. Prior to exercising its option to terminate for cause, the City shall notify the
Contractor of its violation of the particular term(s) of this Agreement, and shall grant
Contractor ten (10) days to cure such default. If such default remains uncured after
ten (10) days, the City may terminate this Agreement without further notice to
Contractor. Upon termination, the City shall be fully discharged from any and all
liabilities, duties, and terms arising out of, or by virtue of, this Agreement.
Notwithstanding the above, the Contractor shall not be relieved of liability to the City
for damages sustained by the City by any breach of the Agreement by the Contractor.
The City, at its sole option and discretion, shall be entitled to bring any and all
legal/equitable actions that it deems to be in its best interest in order to enforce the
City's rights and remedies against Contractor. The City shall be entitled to recover all
costs of such actions, including reasonable attorneys' fees.
5.2 TERMINATION FOR CONVENIENCE OF THE CITY
THE CITY MAY ALSO, THROUGH ITS CITY MANAGER, AND FOR ITS
CONVENIENCE AND WITHOUT CAUSE, TERMINATE THE AGREEMENT AT ANY
TIME DURING THE TERM BY GIVING WRITTEN NOTICE TO CONTRACTOR OF
SUCH TERMINATION; WHICH SHALL BECOME EFFECTIVE WITHIN THIRTY (30)
DAYS FOLLOWING RECEIPT BY THE CONTRACTOR OF SUCH NOTICE. IF THE
AGREEMENT IS TERMINATED FOR CONVENIENCE BY THE CITY,
CONTRACTOR SHALL BE PAID FOR ANY SERVICES SATISFACTORILY
PERFORMED UP TO THE DATE OF TERMINATION; FOLLOWING WHICH THE
CITY SHALL BE DISCHARGED FROM ANY AND ALL LIABILITIES, DUTIES, AND
TERMS ARISING OUT OF, OR BY VIRTUE OF, THIS AGREEMENT.
5.3 TERMINATION FOR INSOLVENCY
The City also reserves the right to terminate the Agreement in the event the
Contractor is placed either in voluntary or involuntary bankruptcy or makes an
assignment for the benefit of creditors. In such event, the right and obligations for
the parties shall be the same as provided for in Section 5.2.
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SECTION 6
INDEMNIFICATION AND INSURANCE REQUIREMENTS
6.1 INDEMNIFICATION
Contractor agrees to indemnify and hold harmless the City of Miami Beach and its officers,
employees, agents, and contractors, from and against any and all actions (whether at law or
in equity), claims, liabilities, losses, and expenses, including, but not limited to, attorneys'
fees and costs, for personal, economic, or bodily injury, wrongful death, loss of or damage to
property, which may arise or be alleged to have arisen from the negligent acts, errors,
omissions or other wrongful conduct of the Contractor, its officers, employees, agents,
contractors, or any other person or entity acting under Contractor's control or supervision, in
connection with, related to, or as a result of the Contractor's performance of the Services
pursuant to this Agreement. To that extent, the Contractor shall pay all such claims and
losses and shall pay all such costs and judgments which may issue from any lawsuit arising
from such claims and losses, and shall pay all costs and attorneys' fees expended by the
City in the defense of such claims and losses, including appeals.
The parties agree that one percent (1%) of the total compensation to Contractor for
performance of the Services under this Agreement is the specific consideration from the City
to the Contractor for the Contractor's indemnity agreement. The provisions of this Section
6.1 and of this indemnification shall survive termination or expiration of this Agreement.
6.2 INSURANCE REQUIREMENTS
The Contractor shall not commence any work and/or Services pursuant to this Agreement
until all insurance required under this Section has been obtained and such insurance has
been reviewed and approved by the City's Risk Manager.
The Contractor shall maintain and carry in full force during the Term, the following insurance:
1. Comprehensive General Liability insurance, to include sexual molestation, in an
amount not less than $500,000 combined single limit per occurrence and $1,000,000
aggregate in a policy year. Deductibles exceeding $1,000 are discouraged, unless
Contractor can provide financial statements to support a higher deductible. The City
of Miami Beach must be designated and shown as an additional insured and the
certificate holder with respects to this coverage. The general liability policy must
contain coverage for the following:
a. Bodily Injury;
b. Property Damage;
c. No exclusions for Abuse, Molestation or Corporal Punishment;
d. No endorsement for premises only operations.
2. If applicable, Contractor Professional Liability insurance, with coverage
amounts not less than $250,000 per claim and in the aggregate. Defense costs
may be inside the limits of liability and the policy can be written on claims made form.
The City of Miami Beach is not required to be named as an Additional Insured.
Professional liability insurance is generally required when the scope of services uses
professional services that require certification or license(s) to provide direct services
to program participants.
3. Workers Compensation & Employers Liability, as required pursuant to Florida
Statutes. Worker's Compensation Insurance must cover all employees, non-
incorporated independent contractors or Contractors, and incorporated independent
contractors or Contractors that do not have worker's compensation coverage or a
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valid State of Florida exemption on file with the Department of Labor, as required by
Florida Statutes, Chapter 440. In the event that the Contractor is no longer exempt
from obtaining Worker's Compensation insurance, the Contractor must notify the City
of Miami Beach and provide the necessary certificate of insurance upon the
termination of the exemption. The employer's liability portion will be
$500,000/$500,000/$500,000 as a minimum.
The insurance must be furnished by insurance companies authorized to do business in the
State of Florida. All insurance policies must be issued by companies rated no less than "B+"
as to management and not less than "Class VI" as to strength by the latest edition of Best's
Insurance Guide, published by A.M. Best Company, Oldwick, New Jersey, or its equivalent.
All of Contractor's certificates shall contain endorsements providing that written notice shall
be given to the City at least thirty (30) days prior to termination, cancellation or reduction in
coverage in the policy. The insurance certificates for General Liability and Professional
Liability shall include the City as an additional insured and shall contain a waiver of
subrogation endorsement.
Original certificates of insurance must be submitted to the City's Risk Manager for approval
(prior to any work and/or services commencing) and will be kept on file in the Office of the
Risk Manager. The City shall have the right to obtain from the Contractor specimen copies of
the insurance policies in the event that submitted certificates of insurance are inadequate to
ascertain compliance with required coverage.
The Contractor is also solely responsible for obtaining and submitting all insurance
certificates for any sub-contractors.
Compliance with the foregoing requirements shall not relieve the Contractor of the liabilities
and obligations under this Section or under any other portion of this Agreement.
Failure by Contractor to comply with Section 6.2 shall be a material breach of this Contract.
The City will not disburse any funds under this contract until all required Certificates of
Insurance have been provided to and have been approved by the City's Risk Manager.
The Contractor shall not commence any work and or services pursuant to this Agreement
until all insurance required under this Section has been obtained and such insurance has
been approved by the City's Risk Manager.
Contractor and or Contractor's insurance agent, as applicable, shall notify the City, in writing,
of any material changes in insurance coverage, including, but not limited to, any renewals of
existing insurance policies, not later than thirty (30) days prior to the effective date of making
any material changes to the insurance coverage except for ten (10) days for lack of payment
changes. Contractor shall be responsible for ensuring that all applicable insurance is
maintained and submitted to the City for the duration of this Contract. In the event of any
change in Contractor's Scope of Services, Attachment A, the City may increase, waive, or
modify in writing any of the foregoing insurance requirements. Any request by a Contractor to
decrease, waive, or modify any of the foregoing insurance requirements must be approved,
in writing, by the City prior to any such decrease, waiver, or modification. In the event that an
insurance policy is canceled, lapsed, or expired during the effective period of this Contract,
the City shall withhold all payments to Contractor until a new Certificate of Insurance required
under this section is submitted and approved. by the City. The new insurance policy shall
cover the time period commencing from the date of cancellation of the prior insurance policy.
The City may require Contractor to furnish additional and different insurance coverage, or
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both, as may be required from time to time under applicable federal or state laws or the City
requirements. Provision of insurance by Contractor, in no instance, shall be deemed to be a
release, limitation, or waiver of any claim, cause of action or assessment that the City may
have against Contractor for any liability of any nature related to performance under this
Contract or otherwise. All insurance required hereunder may be maintained by Contractor
pursuant to a master or blanket policy or policies of insurance.
SECTION 7
LITIGATION JURISDICTIONNENUE/JURY TRIAL WAIVER
This Agreement shall be construed in accordance with the laws of the State of Florida. This
Agreement shall be enforceable in Miami-Dade County, Florida, and if legal action is
necessary by either party with respect to the enforcement of any or all of the terms or
conditions herein, exclusive venue for the enforcement of same shall lie in Miami-Dade
County, Florida. By entering into this Agreement, Contractor and the City expressly waive
any rights either party may have to a trial by jury of any civil litigation related to or arising out
of this Agreement.
SECTION 8
LIMITATION OF CITY'S LIABILITY
The City desires to enter into this Agreement only if in so doing the City can place a limit on
the City's liability for any cause of action, for money damages due to an alleged breach by
the City of this Agreement, so that its liability for any such breach never exceeds the sum of
the compensation/fee to be paid to Contractor pursuant to this Agreement, less any amounts
actually paid by the City as of the date of the alleged breach. Contractor hereby expresses its
willingness to enter into this Agreement with Contractor's recovery from the City for any
damage action for breach of contract to be limited to a maximum amount of the sum of the
compensation/fee to be paid to Contractor pursuant to this Agreement, less any amounts
actually paid by the City as of the date of the alleged breach.
Accordingly, and notwithstanding any other term or condition of this Agreement, Contractor
hereby agrees that the City shall not be liable to the Contractor for damages in an amount in
excess of the sum of the compensation/fee to be paid to Contractor pursuant to this
Agreement, less any amounts actually paid by the City as of the date of the alleged breach
for any action or claim for breach of contract arising out of the performance or non-
performance of any obligations imposed upon the City by this Agreement.
Nothing contained in this section or elsewhere in this Agreement is in any way intended to be
a waiver of the limitation placed upon the City's liability, as set forth in Section 768.28, Florida
Statutes.
SECTION 9
[INTENTIONALLY DELETED]
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SECTION 10
GENERAL PROVISIONS
10.1 AUDIT AND INSPECTIONS
Upon reasonable verbal or written notice to Contractor, and at any time during normal
business hours (i.e., 9AM — 5PM, Monday through Fridays, excluding nationally recognized
holidays), and as often as the City Manager may, in his/her reasonable discretion and
judgment, deem necessary, there shall be made available to the City Manager, and/or such
representatives as the City Manager may deem to act on the City's behalf, to audit,
examine, and/ or inspect, any and all other documents and/or records relating to all matters
covered by this Agreement, including Contractor's financial records. Contractor shall
maintain any and all such records at its place of business at the address set forth in the
"Notices" section of this Agreement. Contractor agrees to submit its agency financial audit
to the City within 30 days of completion, at least once during the Term of this Agreement.
10.2 [INTENTIONALLY DELETETD]
10.3 ASSIGNMENT, TRANSFER OR SUBCONSULTING
Contractor shall not subcontract, assign, or transfer all or any portion of any work and/or
service under this Agreement without the prior written consent of the City Manager, which
consent, if given at all, shall be in the Manager's sole judgment and discretion. Neither this
Agreement, nor any term or provision hereof, or right hereunder, shall be assignable unless
as approved pursuant to this Section, and any attempt to make such assignment (unless
approved) shall be void.
Contractor shall be responsible for all Services performed, and all expenses incurred, under
this Agreement, including services provided and expenses incurred by any and all
subcontractors. The City shall not be liable to any subcontractor for any expenses or
liabilities incurred under any subcontract. Contractor shall be solely liable for any expenses
or liabilities incurred under any subcontract. Contractor shall hold harmless and defend, at
Contractor's expense, the City against any claims, demands or actions related to any
subcontract.
10.4 [INTENTIONALLY DELETED]
10.5 EQUAL EMPLOYMENT OPPORTUNITY
In connection with the performance of the Services, the Contractor shall not discriminate
against any employee or applicant for employment because of race, color, national origin,
religion, ancestry, sex, intersexuality, place of birth, physical handicap, gender identity,
sexual orientation, disability, marital and familial status, or age.
10.6 CONFLICT OF INTEREST
The Contractor herein agrees to adhere to and be governed by all applicable Miami-Dade
County Conflict of Interest Ordinances and ethics provisions, as set forth in the Miami-Dade
County Code, and as may be amended from time to time; and by the City of Miami Beach
Charter and Code (as may be amended from time to time); both of which are incorporated
by reference herein as if fully set forth herein.
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The Contractor covenants that it presently has no interest and shall not acquire any
interest, direct or indirectly, which could conflict in any manner or degree with the
performance of the Services. The Contractor further covenants that in the performance of
this Agreement, Contractor shall not employ any person having such interest. No member
of or delegate to the Congress of the United States shall be admitted to any share or part of
this Agreement or to any benefits arising there from.
SECTION 11
NOTICES
All notices and communications in writing required or permitted hereunder, shall be
delivered personally to the representatives of the Contractor and the City listed below or
may be mailed by U.S. Certified Mail, return receipt requested, postage prepaid, or by a
nationally recognized overnight delivery service.
Until changed by notice in writing, all such notices and communications shall be addressed
as follows:
TO CONTRACTOR: Institute for Child and Family Health, Inc.
Attn: Robert D. Nolan, PH.D., Executive Director
15490 NW 7th Avenue
Miami, Florida 33169
305-688-3541
TO CITY: City of Miami Beach
Office of Housing and Community Services
Attn: Maria Ruiz, Department Director
1700 Convention Center Drive
Miami Beach, Florida 33139
(305) 673-7491
Notice may also be provided to any other address designated by the party to receive notice if
such alternate address is provided via U.S. certified mail, return receipt requested, hand
delivered, or by overnight delivery. In the event an alternate notice address is properly provided,
notice shall be sent to such alternate address in addition to any other address which notice
would otherwise be sent, unless other delivery instruction as specifically provided for by the
party entitled to notice.
Notice shall be deemed given on the day on which personally served, or the day of receipt by
either U.S. certified mail or overnight delivery.
SECTION 12
MISCELLANEOUS PROVISIONS
12.1 CHANGES AND ADDITIONS
This Agreement cannot be modified or amended without the express written consent of the
parties. No modification, amendment, or alteration of the terms or conditions contained herein
shall be effective unless contained in a written document executed with the same formality
and of equal dignity herewith.
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12.2 SEVERABILITY
If any term or provision of this Agreement is held invalid or unenforceable, the remainder of
this Agreement shall not be affected and every other term and provision of this Agreement
shall be valid and be enforced to the fullest extent permitted by law.
12.3 ENTIRETY OF AGREEMENT
The City and Contractor agree that this is the entire Agreement between the parties. This
Agreement supersedes all prior negotiations, correspondence, conversations, agreements or
understandings applicable to the matters contained herein, and there are no commitments,
agreements or understandings concerning the subject matter of this Agreement that are not
contained in this document. Title and paragraph headings are for convenient reference and
are not intended to confer any rights or obligations upon the parties to this Agreement.
12.4 CONTRACTOR'S COMPLIANCE WITH FLORIDA PUBLIC RECORDS LAW
Pursuant to Section 119.0701 of the Florida Statutes, if the Contractor meets the definition of
"Contractor" as defined in Section 119.0701(1)(a), the Contractor shall:
a) Keep and maintain public records that ordinarily and necessarily would be required
by the public agency in order to perform the service;
b) Provide the public with access to public records on the same terms and conditions
that the public agency would provide the records and at a cost that does not exceed
the cost provided in this chapter or as otherwise provided by law;
c) Ensure that public records that are exempt or confidential and exempt from public
records disclosure requirements are not disclosed except as authorized by law; and
d) Meet all requirements for retaining public records and transfer to the City, at no City
cost, all public records created, received, maintained and/or directly related to the
performance of this Agreement that are in possession of the Contractor upon
termination of this Agreement. Upon termination of this Agreement, the Contractor
shall destroy any duplicate public records that are exempt or confidential and exempt
from public records disclosure requirements. All records stored electronically must
be provided to the City in a format that is compatible with the information technology
systems of the City.
For purposes of this Article, the term "public records" shall mean all documents, papers,
letters, maps, books, tapes, photographs, films, sound recordings, data processing software,
or other material, regardless of the physical form, characteristics, or means of transmission,
made or received pursuant to law or ordinance or in connection with the transaction of official
business of the City.
Contractor's failure to comply with the public records disclosure requirement set forth in
Section 119.0701 of the Florida Statutes shall be a breach of this Agreement.
In the event the Contractor does not comply with the public records disclosure requirement
set forth in Section 119.0701 of the Florida Statutes, the City may, at the City's sole
discretion, avail itself of the remedies set forth under this Agreement and available at law.
12.5 BACKGROUND SCREENING
In accordance with Sections 39.001, 943.0542, 984.01, and 1012.465, and Chapters 402,
430, 435, Florida Statutes, as applicable, employees, volunteers and subcontracted
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personnel who work_in direct contact with children or who come into direct contact with
children must complete a satisfactory Level 2 background screening prior to commencing
work pursuant to this Agreement.
Level 2 background screening investigations must be completed through the Florida
Department of Law Enforcement (FDLE) VECHS (Volunteer & Employee Criminal History
System) Program. Satisfactory background screening documentation will be accepted for
those agencies that already conduct business with either the Department of Children and
Families (DCF) or the Department of Juvenile Justice (DJJ) or the Miami-Dade County Public
School System (MDCPS). A clearance letter from MDCPS Office of Employment Standards
indicating the person has successfully completed a Level 2 screening shall be acceptable by
the City.
If background screenings are completed through VECHS, then Contractor shall complete
Attachment E: "Affidavit for Level 2 Background Screenings," for each contract term. The
Affidavit shall cover employees, volunteers, and subcontractors performing services under
this contract who are required to complete a Level 2 background screening as defined in this
section. Contractor shall keep Attachment E: "Affidavit for Level 2 Background Screenings" in
Contractor's records for its personnel, volunteers, and sub-contractors. Contractor shall re-
screen each employee, volunteer, and/or subcontractor every five (5) years.
12.6 CONFIDENTIALITY
Contractor and the City understand that during the course of performing the Services
hereunder, each party may have access to certain confidential and proprietary information
and materials of the other party in order to further performance of the Services. The parties
shall protect confidential information and comply with applicable federal and state laws on
confidentiality to prevent unauthorized use, dissemination or publication of confidential
information as each party uses to protect its own confidential information in a like manner.
The parties shall not disclose confidential information to any third party (except that such
information may be disclosed to such party's attorneys), or to any employee of such party
who does not have a need to know such information, which need is related to performance of
a responsibility hereunder. However, this Agreement imposes no obligation upon the parties
with respect to confidential information which (a) was lawfully known to the receiving party
before receipt from the other, (b) is or becomes a matter of public knowledge through no fault
of the receiving party, (c) is rightfully received by the receiving party from a third party without
restriction on disclosure, (d) is independently developed by or for that party, (e) is disclosed
under operation of law, (f) is disclosed by the receiving party with the other party's prior
written approval, or (g) is subject to Chapter 119 of the Florida Statutes or is otherwise
required to be disclosed by law. The confidentiality provision of this Agreement shall remain
in full force and effect after the termination of this Agreement.
12.7 DATA SECURITY OBLIGATION
Contractor shall maintain an appropriate level of data security for the personally identifiable
information (PII) Contractor is collecting or using in the performance of this Contract. PII is
information that can uniquely identify, contact, or locate a single person or can be used with
other sources to uniquely identify individuals. Contractor shall maintain and adhere to a
written Data Security Policy that addresses requirements regarding the protection of PII from
unauthorized access and protection against data breaches and ensures Contractor is in
compliance with applicable federal and state standards with respect to transmission, receipt
and storage of PII on Contractor's computing network and as paper records. This policy shall
address the topics of computer passwords, screensavers that lock computers, securing
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physical facilities, storing data, data use, data confidentiality agreements, and staff training
related to the policy. Additionally, Contractor is responsible for approving and tracking all
Contractor employees who request system or information access and ensuring that user
access has been removed from all terminated employees of Contractor. All employees and
independent contractors performing work or duties related to this Contract will sign a Data
Confidentiality Agreement prior to beginning work related to this Contract. Contractor must
also abide by all requirements to protect client protected personally identifiable information
(PPII).
Contractor shall fully comply with the data security obligations set forth in the Children's Trust
Grant Agreement, at Section 0-12, entitled "Data Security Obligation."
12.8 CHILDREN WITH DISABILITIES AND THEIR FAMILIES
Contractor understands that the City expects Contractor to meet any and all federal
standards under the Americans with Disabilities Act. Contractor must also implement
reasonable programmatic accommodations to include children with disabilities and their
families, whenever possible. Notwithstanding anything to the contrary, Contractor shall not
be required to make any alteration to any public school building or other building or structure
which is not owned by Contractor.
12.9 RESPONSIBILITY OF THE CONTRACTOR
With respect to the performance of the Services, the Contractor shall exercise that degree of
skill, care, efficiency and diligence normally exercised by recognized professionals with
respect to the performance of comparable services. In its performance of the Services, the
Contractor shall comply with all applicable laws, ordinances, and regulations of the City,
Miami-Dade County, the State of Florida, and the federal government, as applicable.
12.10 PATENT RIGHTS; COPYRIGHTS; CONFIDENTIAL FINDINGS
Any and all documents prepared by Contractor pursuant to this Agreement are related
exclusively to the work and/or services described herein, and are intended or represented
for ownership by the City. Any re-use, distribution, or dissemination of same by Contractor,
other than to the City, must first be approved in writing by the City Manager, which
approval, if granted at all, shall be at the City Manager's sole and absolute discretion.
Any patentable and/or copyrightable result arising out of this Agreement, as well as all
information, specifications, processes, data and findings, shall be made available to the
City, in perpetuity, for public use.
No reports, other documents, articles or devices produced in whole or in part under this
Agreement shall be the subject of any application for patent or copyright by or on behalf of
the Contractor (or its employees or sub-contractors, if any) without the prior written consent
of the City Manager, which consent, if given at all, shall be at the Manager's sole and
absolute discretion.
THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.
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IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be
executed by their appropriate officials, as of the date first entered above.
FOR CITY: CITY OF MIAMI BEACH, FLORIDA
ATTEST:
By: __
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City Cler City anager
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EXHIBIT "A" -
•
"SCOPE OF SERVICES"
All Services related to this Agreement that are provided to minor children or youth must be
administered in the presence of the minor's parent or legal guardian. Alternatively, the
Services may be provided in a safe, public space (e.g. the minor's school), but only if
approved in writing by the parent or legal guardian and the City.
The Contractor agrees to provide the following services to youth enrolled in the City of Miami
Beach Success University program:
Service Units Documentation of Service
of
Service
Functional 25 Completion and execution of the following documents:
Family Therapy • Programmatic Attendance Form signed by all attendees, for
Session all sessions, including intake/ assessment for services and
direct client service provision sessions
• Youth Outcome Questionnaire (pre-test); one per each client
family.
• Youth Outcome Questionnaire (post-test) one per each client
family.
Notification email, to be sent from Contractor to City staff
within 72 hours of service delivery.
Related Definitions:
Functional Family Therapy Services — Functional Family Therapy Services (FFTS) are
conducted by the Consultant's staff in accordance with the Consultant's policies and
procedures and in accordance with the Evidence-Based Program's certification standards.
The contents of and information discussed during the FFTS remain private, unless the
Consultant deems specific information to be relevant and/or important for the City's provision
of other services, or if information compiled in the FFTS is deemed to be relevant to the
safety of the client or others. The FFTS is documented by the full and accurate completion of
the Programmatic Attendance Form and includes the signatures of the client receiving the
service, clinician providing the service, and any additional individuals receiving or providing
services referenced herein. The FFTS is further documented by the Youth Outcome
Questionnaire (pre-test and post-test) for the purposes of recording outcome measures.
Should the Contractor encounter challenges in meeting the below stated service
deliverables within the required timeframes, the Contractor may request an extension.
The approval and duration of all extensions are at the sole discretion of the City. If the
Contractor is unable to satisfy deliverables within the required timeframes, the City
reserves the right to conduct said services or assign said services to an alternate
vendor at its sole discretion.
Services must be provided in accordance with the below timeline and in response to
client needs. If the Contractor is found to be providing services primarily during the
second half of any calendar month, the City reserves the right to request
documentation to explain the delay in service provision.
13
Service Deliverables
Services must be delivered as follows:
Service Unit of Service Service Timeframe
Location
Functional Minimum of 10 Client Home Initial FFTS Intake/Assessment
Family Therapy sessions for session will be completed within fifteen
Services each of up to 25 (15) days of referral. All eligible FFTS
children/families will be completed within one hundred
sixty (160) days of completed FFTS
Intake/Assessment session.
Service Documentation
Services will be deemed as provided when the following documentation is provided within the
noted timeframes:
Service Submission Deadline
Referrals • Miami Beach Service Partnership Three (3) business days
Referral Form(s) signed by staff and from the identification of
receiving client(s). client need
Functional Family • Programmatic Attendance Form signed Notification Email: three
Therapy Services by all in attendance (3) business days from
• Notification Email provision of service.
•Internal documentation for the Programmatic Attendance
Contractor's records should be kept in Form: monthly; by the 3rd
accordance with the Contractor's policies day of the succeeding
and procedures and in accordance with the month.
Evidence-Based Program's certification
standards.
Penalties for Failure to Perform
If the Contractor fails, on two occasions, to submit required, accurate documentation in the
timeframe allotted, including the absence of notification email, the Contractor will forfeit two
(2%) percent of the combined billed total for the months in which inaccuracies took place.
Documents submitted within the required timeframe and found to be insufficient are subject
to penalties for failure to perform.
If the Contractor fails, on three occasions, to submit required, accurate documentation in the
timeframe allotted within the contract Term, the Contractor is subject to the termination by the
City of any further service referrals, but Contractor will be allowed to complete the service
units allotted to existing clients. The decision to cease additional referrals rests in the sole
discretion of the City.
"Required, accurate documentation" may refer to:
• Monthly invoices
• Monthly narratives
• Monthly client lists
• Monthly in-kind hours
• Client Assessments
14
• Service documentation of any kind, including sign-in sheets
• Family Group Conference documents
• Any documents associated with service provision, Service Evaluation forms, or any
other documentation required by this Agreement.
• Performance Measurement Tools
• Notification Emails
• Any document required by this Agreement
If any individual employed by or independently contracted with the Contractor fails, on more
than one occasion, to attend a scheduled client meeting without notifying the City of an
impending absence, the City reserves the right to remove that individual from the
Contractor's staff roster for the purposes of this Contract.
If the Contractor is unable to fulfill the contracted service level within the allocated timeframe
for each service component, the City reserves the right to reduce service levels accordingly
across the funded service spectrum and terminate this Agreement at its discretion.
If the Contractor is unable to fulfill the contracted service level and the City subsequently
reduces service and funding levels, the City reserves the right to select another vendor to
fulfill the remaining service units. The City will select the alternate vendor at its sole
discretion.
Engagement Strategies
The Contractor will adhere to the following engagement strategies in the delivery of services:
• Provide client and his/her parents and/or guardians information regarding the
importance of adhering to school attendance policies, if applicable.
• Provide client and his/her parents and/or guardians information regarding the Care
Coordination process and all other available services.
• Reintroduce the services available through the Program at each client interaction.
• Document every interaction with or on behalf of the client.
Employee/ Contractor File Review
The following documentation must be included in the employee/contractor file for all
employees/contractors providing services under this contract.
The following must be included in the employee files:
• Employment Application
• Evidence of degree/credentials
• Job Description Signed by Employee
• Evidence of Required Experience
• Florida Background Criminal Screening
• National FBI Background Criminal Screening (Level 2)
• Affidavit of Good Moral Character
• Proof of Knowledge of Policies & Procedures
• Confidentiality Agreement Re: Client Information
• Authorized time sheets, records, and attendance sheets to document the staff time
billed to provide Services pursuant to this Agreement
15
• Daily activity logs and monthly calendars of the provision of Services pursuant to this
Agreement
• Documentation of Contractor Training/In-Service Training
• Documentation of City-provided trainings •
• Documentation of attendance at one CCDH training
• 1-9 Verification on File
Monitoring visits shall take place within thirty (30) days of the commencement of services.
The City will notify the Contractor a minimum of five (5) business days' notice prior to a
monitoring visit.
The City reserves the right to inspect employee/contractor files with due notice (at least forty-
eight (48) hours in advance of planned site visit) to ensure adherence to contractual
expectations as well as to ensure pre-screening prior to a monitoring visit by The Children's
Trust.
Evaluation
In the continuing effort to ensure programming excellence, clients will be provided with
evaluation forms at the end of each programming component to gauge their satisfaction with
services provided. At a minimum, the Contractor must obtain evaluation forms from the
primary child client and the parent/guardian. The evaluation forms will be provided by the City
and must be administered at the following times:
• Completion of Family Group Conference
• Completion of Care Plan Close-Out (program evaluation form)
The City will conduct intermittent performance evaluations for the purpose of monitoring the
Contractor's performance. The City will conduct said evaluations utilizing a tool of its choice
and at its sole discretion.
Reporting Requirements
Each month, the Contractor will provide the City with a Monthly Progress Report, Client List,
and Reimbursement Request utilizing the City's Reporting and Reimbursement Forms
(Exhibit B) by 5:00 PM on the fifth (5th) of the following month. The client list detailing the
dates, services provided, and clients receiving said services must be included. If in-kind
hours are submitted, back-up documentation stating same must be included. In the event
that the third of the month lands on a Saturday, Sunday or holiday, the report must be
submitted the following business day. Reports are due to the City on the following dates:
• Thursday, November 5, 2015 • Tuesday, April 5, 2016
• Monday, December 7, 2015 •Thursday, May 5, 2016
• Tuesday, January 5, 2016 • Monday, June 6, 2016
• Friday, February 5, 2016 • Tuesday, July 5, 2016
• Monday, March 7, 2016 • Friday, August 5, 2016
Monthly reports and reimbursement requests may be submitted via any of the following
methods:
• Electronic mail
• Facsimile
16
• Standard mail
• Hand delivery
Monthly reports will not be considered acceptable unless the following is met:
• Forms are completely and accurately filled
• Necessary back-up materials are included (service documentation, sign-in sheets,
etc.)
• Reports bear the signature of the authorized agency representative submitting the
report on behalf of the Contractor
The City will document Contractor service level data and monthly reports via Active Strategy
software for inclusion in the monthly report to the Miami Beach Service Partnership
Governing Board as well as the City's website.
Miami Beach Service Partnership Meeting Attendance
The Contractor is required to have representation at each calendared Miami Beach Service
Partnership Governing Board meeting. In the event a representative cannot attend in person,
arrangements can be made for a telephonic connection no more than twice per contract
year.
If the Contractor fails to have representation at two meetings, the City reserves the right to
reduce contracted service levels at its sole discretion.
Monitoring & Performance Reviews
The City of Miami Beach reserves the right to inspect, monitor and/or audit the Contractor to
ensure contractual compliance. This includes, but is not limited to:
• Review of on-site service delivery
• Inspection and review of client, budgetary and employee files (for those employees
providing services under this Agreement)
The monitoring tool provided by The Children's Trust, On-Site Monitoring Tool, will be used to
guide inspections and monitoring visits. (Copy included herein.)
Monitoring visits will take place within thirty (30) days of the commencement of services. The
City will notify the Contractor a minimum of five (5) business days' notice prior to a monitoring
visit.
Partner Performance Ratings
The Contractor agrees that its Partner Performance Rating, the score awarded for
performance on the following measures, will be posted on the City's website on a bi-annual
basis:
• Timely and accurate submission of monthly progress report
• Timely and accurate submissions of monthly financial reports (reimbursement
requests)
• Delivery of contracted service units
• Promotion of the Miami Beach Service Partnership
17
• Attendance at Miami Beach Service Partnership Governing Board and related
committee(s) meetings
Ratings will be given for each performance measure based on the following:
Performance Measure Rating Rationale & Score
Timely and accurate submission of Monthly > "0" for failing to submit on time
Service Summary Report > "15" for submitting on time
Timely and accurate submissions of ➢ "0" for failing to submit accurate report with
monthly financial reports (Monthly back-up material on time
Reimbursement Request) > "15" for submitting accurate report on time
Delivery of contracted service units Possible score of 0 to 40 based upon
completion of projected service units. Score is
calculated by dividing the completed number of
service units by the total number of referred
service units.
Timely and complete document submission Possible score of 0 to 10 based upon timely
and complete submission of service
documentation. Score is calculated by dividing
the number of service units submitted timely
and satisfactorily by the total number of service
units completed.
Attendance at Miami Beach Service Possible score of 0 to 20:
Partnership and related committee(s) 10 Points for attendance at Miami Beach
meetings Service Partnership meetings; 10 points for
Committee attendance (In the event that there
are no committee meetings scheduled, the
value for attendance at the Miami Beach
Service Partnership meeting will be 20.)
Promotion & Public Relations Requirements
The Contractor agrees to receive Success University Program Brochures and make them
available to clients during all in-person client interactions.
The Contractor agrees to link its website to the City's Success University webpage. Such link
must be in place prior to the execution of this contract.
The Contractor agrees to indicate its membership in the Partnership in all self-produced
marketing materials that are produced for the benefit of youth and families.
Training Requirements
Personnel providing services under in this Contract will be required to complete the following
trainings prior to service provision, as delineated below:
Functional Family Therapy Services ❑ Program Overview Training
❑ CCDH Disability awareness training
❑ DCF Abuse & Neglect Online Training
18
The Contractor agrees to send at least one representative to attend a City-sponsored grant
writing workshop by July 31, 2016. Alternately, the Contractor may submit documentation
indicating at least one member of its staff has attended another Grant Writing training in the
same period of time.
The Contractor agrees to send its Miami Beach Service Partnership Meeting representative
to a City-sponsored member refresher training at a minimum of once every two years.
In the event that any Contractor staff member does not satisfy the above training
requirements, the City reserves the right to remove the staff member from the Contractor's
roster for the purposes of this Agreement, at its sole discretion.
Client Termination
Contractor staff must notify the Program Coordinator of client inactivity. If the Contractor has
not been able to reach a client they must notify the Program Coordinator by the fourteenth
(14) day.
Contractor's Staff Roster
Contractor will provide the City with following information for each individual employed by or
independently contracted with the Contractor to conduct"services related to this Agreement:
• Name
• Resume
• Credentials, to include degrees and licenses, as required by position
• Phone number
• E-mail address
• Days and times available for service provision (minimum of three weeknight or
weekend shifts available per week)
• Language Skills (minimum of one bilingual staff member required per every 10
contractually required clients)
• Total number of hours per week each staff member is able to commit
• Name of Supervisor and total number of hours per week committed to
supervision/staffing in support of activities related to this Agreement.
Contractor agrees to adhere to screening staff and contracted employees for minimum
requirements appropriate to positions related to this Agreement and in accordance with
Contractor's policies and procedures.
Contractor's staff members are required to wear identification while conducting services.
Contractor's employees and independent contractors providing Mental Health services and/or
Counseling Sessions must meet the following criteria, at minimum:
• A minimum of an earned master's degree from a mental health counseling program or.
a program in a closely related field that is CACREP and/or regionally accredited
• Licensed as Registered Mental Health Counselor Intern or higher in the State of
Florida
• Obtained a mental health counselor qualified supervisor
19
Switchboard of Miami Registration
Contractor agency will register with Switchboard of Miami to ensure that agency information
is accurate and updated. This contractual obligation is directed by The Children's Trust.
Agency registration can be done at the following website: www.switchboardmiami.orq
Additional Documentation
The following documentation must be submitted with this executed agreement:
• All required insurance certificates
• Copy of current financial audit
• Copy of required business licenses and permits
• List of all members of Contractor's Board of Directors, if applicable
• Contractor's Board of Directors by-laws, if applicable
• Conflict of Interest policy
• Agency 990 Form
• Agency W-9 Form
THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.
20
EXHIBIT "B"
INVOICING
The Contractor agrees to provide the invoicing and services documentation as indicated
utilizing the following forms attached herein:
• Monthly Service Summary Report, and
• Monthly Reimbursement Request
• Monthly Client Status List
21
1
EXHIBIT "C"
ATTACHMENTS
The following reference documents are attached:
• The Children's Trust Grant Agreement
22
® Institute
for Child November 13, 2015
Q_
® 06 Family
Hlealth® City of Miami 1700 Convention Center Dr.
WWW.ICFHINC.ORG Miami Beach, Florida 33139
ROBERT D. NOLAN,PH.D. Re: Background Screening Requirements Program Year 2015-16
INTERIM EXECUTIVE DIRECTOR The Children's Trust Contract#1610-1090
Officers
Dear Talmage Thornhill:
Henry E. Landa,CFP
President This letter is written to confirm that each of the following staff working under this contract
have successfully completed the required Level 2 Background Screening.
Eve J. Lominac,CPA
Vice-President Employee Names:
Armando Graupera
Secretary 1. Jaika Selesky. M.S.
2. Farah Southwell, LMHC
Thomas E. Garland, CPA
Treasurer
Board of Directors Sincerely,
Henry E. Landa,CFP
Eve J. Lominac,CPA
Armando A.Graupera
Thomas E.Garland,CPA `�"�,
Victor Balestra,MBA V ''—..,
Lisa Sanders Dr. Robert D. Nolan, Ph.D.
Interim Executive Director
Advisory Council Institute for Child& Family Health, Inc.
Antonio N. Fines,Ph.D. 15490 NW 7th Avenue
J. Bruce Irving, Esp. Miami, FL 33169
Robin Lander,CLU
Michael P.Connolly, Ph.D.
Felix Martinez
Sydney Neuhaus
Betty Metcalf,Ph.D., Emeritus
Dean Schwartz
Accredited by:
The American Psychological
Association(APA)
(Pre-Doctoral Clinical Psychology
Internship Program)
Institute for Child and Family Health,lnc.* Functional Family Therapy Program*15490 NW 7 Av.Miami,FL 33169*Tel:305-685-0381 *
Fax:305-681-7962* www.ICFHinc.org
„,A,„0, ' United i it) ' ' --C. 4
cowl Way ,. '
• l` The au,zn•:r„6r
VUmted WaydN*,*.ad, k
1
Affidavit under Penalty of Perjury for Level 2 Background Screenings
Affidavit under Penalty of Perjury Affirming Compliance with Background Screening for Provider Personnel,
Volunteers, and Subcontracted Personnel, as applicable.
In accordance with Sections 943.0542, 984.01, Chapter 430, 435, 402, 39.001, and 1012.465 Florida
Statutes, and pursuant to the requirements of Paragraph R. Background Screening of this Contract, the
undersigned affiant makes the following statement under oath and under penalty of perjury, which is a
first degree misdemeanor, punishable by a definite term of imprisonment not to exceed one year and/or
a fine not to exceed $1,000, pursuant to Sections 837.012 and 775.082, Florida Statutes.
All full-time, part-time, contracted staff and volunteers, along with the staff and volunteers provided to the
program by a subcontractor have been checked against The Dru Sjodin National Sex Offender Public
Website http://www.nsopw.gov/eng (Check must have taken place within 30 calendar days prior to the
signing of this document.)
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
Before me, the undersigned authority, personally appeared ( ! - _ • - ■ • - or) Authorized Provider
Representative of / C , who being by me first duly sworn, deposes and says:
I swear and affirm that the above-named contracted Provider is compliant with the requirements for
personnel background screening detailed in Sections 943.0542, 984.01, Chapter 435, 402, 39.001, and
1012.465 Florida Statutes, as applicable, for all personnel having direct contact with children.
,Cee /i412/,s-
(Signature of CEO/Executive Director Director) Date
Sworn to and subscribed before me at Miami-Dade County, Florida this}i day of -,A , 20��-key
Who is personally known to me
Who produced identification:
Type of identification
Y,/ _ " NIVIA ESTHER PE NA
gnature of otary Public QAa���r'°s
., �-� o NOTARY PUBLIC
State of Florida at Large T � STATE OF FLORIDA
Comm#EE181879
"s r.:E Ms; Expires 7/20/2016
Print, type or stamp name of notary public
My Commission Expires:
.l '
. ,�= CHILD CARE
•
r: .rtr AFFIDAVIT OF GOOD MORAL CHARACTER
�•
t.I ;MIL IEF.Co`-1
State of Florida County of vq. (4 xi 1 J
Before me this clay personally appeared k, SO IAV ,1 who,being duly sworn,deposes and says:
- (App leant•s.Employee's Name)
As an applicant for employment with,an employee of,a volunteer for,or an applicant to'.oltinteer with , I
affirm and attest under penalty of perjury that I meet the moral character requirements for-employ ment,as required by Chapter 435 Florida Statutes in
that:•
I have not been arrested with disposition pending or found guilty of,regardless of adjudication,or entered a plea of nolo contendere or guilty to,or have
been adjudicated delinquent and the record has not been sealed or expunged for,any offense prohibited under any of the following provisions of the
Florida Statutes or under any similar statute of another jurisdiction for any of the offenses listed below:
Relating to:
Section 393.135 sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct
Section 394.4593 sexual misconduct with certain mental health patients and reporting of such sexual misconduct
Section 415.111 adult abuse,neglect,or exploitation of aged persons or disabled adults or failure to report of such abuse
Section 741.28 criminal offenses that constitute domestic violence,whether committed in Florida or another jurisdiction
Section 782.04 murder
Section 782.07 manslaughter,aggravated manslaughter of an elderly person or disabled adult,or aggravated manslaughter of a child
Section 782.071 vehicular homicide
Section 782.09 killing an unborn quick child by injury to the mother
Chapter 784 assault,battery,and culpable negligence, if the offense was a felony
Section 784.011 assault,if the victim of offense was a minor
Section 784.03 battery,if the victim of offense was a minor
Section 787.01 kidnapping
Section 787.02 false imprisonment
Section 787.025 luring or enticing a child
Section 787.04(2) taking,enticing,or removing a child beyond the state limits with criminal intent pending custody proceeding
Section 787.04(3) carrying a child beyond the state lines with criminal intent to-avoid producing a child at a custody hearing or delivering the
child to the designated person
Section 790.115(1) exhibiting firearms or weapons within 1,000 feet of a school
Section 790.115(2)(b) possessing an electric weapon or device,destructive device,or other weapon on school property
Section 794.011 sexual battery
Former Section 794.041 prohibited acts of persons in familial or custodial authority
Section 794.05 unlawful sexual activity with certain minors
Chapter 796 prostitution
Section 798.02 lewd and lascivious behavior
Chapter 800 lewdness and indecent exposure
Section 806.01 arson
Section 810.02 burglary •
Section 810.14 voyeurism,if the offense is a felony
Section 810.145 video voyeurism, if the offense is a felony
Chapter 812 theft and.or robbery and related crimes,if a felony offense
Section 817.563 fraudulent sale of controlled substances,if the offense was a felony
Section 825.102 abuse,aggravated abuse,or neglect of an elderly person or disabled adult
Section 825.1025 lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult
Section 825.103 exploitation-of disabled adults or elderly persons, if the offense was a felony
Section 826.04 incest
Section 827.03 child abuse,aggravated child abuse,or neglect of a child
Section 827.04 contributing to the delinquency or dependency of a child
Former Section 827.05 negligent treatment of children
Section 827.071 sexual performance by a child
Section 843.01 resisting arrest with violence
Section 843.025 depriving a law enforcement,correctional,or correctional probation officer means of protection or communication
Section 843.12 aiding,in an escape
Section 843.13 aiding in the escape of juvenile inmates in correctional institution
Chapter 847 obscene literature
loft
CF-FSP 1649A Child Care Affidavit of Good Moral Character, July 2012, 65C-22.006 F.A. C.
•
•
Section 874.05(1) encouraging or recruiting another to join a criminal gang
Chapter 893 drug abuse prevention and control only if the offense was a felony or if any other person involved in the offense was a
minor
Section 916.1075 sexual misconduct with certain forensic clients and reporting of such sexual conduct
Section 944.35(3) inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm
Section 944.40 escape
Section 944.46 harboring,concealing,or aiding an escaped prisoner
Section 944.47 introduction of contraband into a correctional facility
Section 935.701 sexual misconduct in juvenile justice programs
Section 935.711 contraband introduced into detention facilities •
I understand that[must acknowledge the existence of any applicable criminal record relating to the above lists of offenses including those under any
similar statute of another jurisdiction,regardless of whether or not those records have been sealed or expunged.Further,I understand that, while
employed or\,olunteering at in any position that requires background screening as a "
condition of employment,[must immediately notify my supervisor employer of any arrest and any changes in my criminal record involving any of the
above listed provisions of Florida Statutes or similar statutes of another jurisdiction whether a misdemeanor or felony.This notice must be made within
one business day of such arrest or charge.Failure to do so could be grounds for termination.
[attest that I have read the above carefully and state that my attestation here is true and correct that my record does not contain any of the above listed
offenses.I understand,under penalty of perjury,all employees in such positions of trust or responsibility shall attest to meeting the requirements for
qualifying for employment and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses.I also understand that it is
my responsibility to obtain clarification on anything contained in this affidavit which I do not understand prior to signing.I am aware that any omissions,
falsifications,misstatements or misrepresentations may disqualify me from employment consideration and,if I am hired,may be grounds for termination
or denial of an exemption at a later date.
SIGNATURE OF AFFIANT: iLSOWMAiti&Q,P
•
Sign Above OR Below, DO NOT Sign Both Lines
To the best of my knowledge and belief,my record contains one or more of the applicable disqualifying acts or offenses listed above.I have placed
a check mark by the offense(s)contained in my record.(If you have previously been granted an exemption for this disqualifying offense,please
attach a copy of the letter granting such exemption.)(Please circle the number which corresponds to the offense(s)contained in your record.)
SIGNATURE OF AFFLANT:
Sworn to and subscribed before me this a day of1‘tr. ,20 1,6
i��"G-Z IG�! 5� � `'u — .. •
SIGNATURE OF NOTARY PUBLIC,STATE FLORIDA
W05-6 ( )7Uli H .
(Print,Type,or Stamp Commissioned Name of Notary Public)
•spar •,i,
�` �� ROSE DURAN-MARVEY
4 ,\ �� Notary Public•State of Florida
4 % r My Comm.Expires Jan 23,201$
Check one �''.,,os� •.••' Commission I EE 134197
Affiant personally known to notary
OR •
T. Affiant produced identification
Type of identification produced:
?of 2
CF-FSP 1649A Child Care Affidavit of Good Moral Character, July 2012, 65C-22.006 F. A.C.
•
Child Abuse & Neglect Reporting Requirements
All child care personnel are mandated by law to report their suspicions of child abuse, neglect,
or abandonment to the Florida Abuse Hotline in accordance with s. 39.201 of the Florida
Statutes (F.S.).
• Child care personnel must be alert to the physical and behavioral indicators of child abuse and
neglect. "Child Abuse or Neglect" is defined in s. 39.201. F.S., as "harm or threatened harm" to a
child's health (mental or physical) or welfare by the acts or omissions by a parent'adult household
member, other person responsible for the child's welfare, or for purposes of reporting requirements
by any person.
•
Categories include:
- Physical Abuse or Neglect (i.e. unexplained bruises, hunger, lack of supervision...)
- Emotional Abuse or Neglect (i.e. impairment in the ability to function, depression...)
- Sexual Abuse (i.e. withdrawal, excessive.crying, physical symptoms...)
• Reports must be made immediately to the Florida Abuse Hotline Information System by
- Telephone at 1-800-96-ABUSE (1-800-962-2873), or
- Fax at 1-800-914-0004, or
- Online at http://www.dcf.state.fl.us/abuse/report/.
Failure to perform duties of a mandatory reporter pursuant to s. 39.201, F.S. constitutes a violation
of the standards in ss. 402.301-319, F.S. and is a felony of the third degree. Remember, it is each
child care personnel's responsibility to report suspected abuse and/or neglect.
• All reports are confidential. However, persons who are mandated reporters (child care personnel)
are required to give their name when making a report.
* It is important to give as much identifying and factual information as possible when making a report.
* Any person, when acting in good faith, is immune from liability in accordance with s. 39.203(1)(a),
F.S.
* For more information about child abuse and neglect, visit the Department's website at
www.myflorida.com/childcare and select "Training Requirements." The Department offers a 4-hour
Identifying and Reporting Child Abuse and Neglect course for child care providers. This course is
an overview of the various types of abuse and neglect, indicators that may be observed, the legal
responsibility of mandatory reporters, and the proper procedure for reporting abuse and neglect, as
required by ss. 402.305(2) and 402.313(1), F.S. The course is offered both online and instructor-
. based throughout Florida.
This statement is to verify that on I I I o`Z , 2015 , I, FC-1 K ` cQL/1 ij 1 �,,,� �
�
ate Print Name of Employee
Read an/understood the information and my mandated reporting requirements.
LaA D
Signa' re o Employee (for faci'ityor'srgeFami!y oh,d_a-eHome' Signature of Operator
CF-FSP 5337,October 2012 [65C-22.006(4)(c)&65C-20.008(5), F.A.C.
•