012-19 - Kitsap County - ContractKC-078- r 9
AGREEMENT FOR PROVISION OF JUVENILE DETENTION FACILITIES
BETWEEN KITSAP COI-]NTY AND THE CITY OF PORT ORCHARD
This AGREEMENT FOR THE PROVISION OF JUVENILE DETENTION FACILITIES
("Agreement") is entered into by and between Kitsap County ("County"), d political subdivision
of Washington State, and the City of Port Orchard, a municipal corporation of Washington State
("City").
RECITALS
WHEREAS, the County is authorrzed by law to operate the Kitsap County Juvenile Detention
Facility ("Detention Facility") to confine juvenile offenders;
WHEREAS, the City does not possess sufficient facilities to confine juvenile offenders;
WHEREAS, the County has space available in its Detention Facility and is amenable to making such
space available to confine the City's juvenile offenders, pursuantto the lawful authority of the City,
for a rate of compensation as mutually agreed to by the parties; and
WHEREAS, the County and the City have determined that it would be mutually beneficial to the
parties to enter into this Agreement.
AGREEMENT
NOW, THEREFORE, in consideration of the foregoing recitals which are incorporated herein by
this reference, the parties agree as follows:
SECTION 1 DEFINITIONS
1.1 "Admitted" or "Admission" of the Juvenile by Kitsap County will occur when the Detention
Facility staff has advised City's Representative that the Juvenile presented to the Detention
Facility for confinement has been accepted for admission by the Detention Facility, the
booking process completed, and Kitsap County has taken physical control of the Juvenile.
1.2 "Additional Health Care Services" means any medical, mental health, dental or other form
of health care and/or treatment provided to a Juvenile not routinely provided by Kitsap
County's in-house health care provider in the Detention Facility, regardless of where such
services are provided including, without limitation, emergency medical services,
prescriptions, laboratory tests, medical imaging services, necessary durable medical
equipment, and any in-patient or out-patient treatment or referral.
1.3 "Bed-Day" means any consecutive period of time exceeding 12 hours during which a
Juvenile is in the custody of the Kitsap County Juvenile Department Detention Facility,
which includes booking.
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1.4 "Booking" means the process in which the Juvenile's personal data is recorded, the City's
Representative confirms the Juvenile's identity and the lawful basis for confinement, and
any other screening process routinely required by the Detention Facility prior to
Admission.
1.5 "City Representative" means an authorized member of the City of Port Orchard Police
Department or other authorized representative of the City.
1.6 "Detention Facility" means Kitsap County Juvenile Department Detention Facility.
1 .7 "Detention Manager" means the Manager of the Kitsap County Juvenile Detention Facility
or his/her designee.
1.8 "Gravely Disabled" means a person who, as a result of a mental disorder, is in danger of
serious physical harm resulting from a failure to provide for hisftrer essential human needs
of health or safety; or manifests severe deterioration in routine functioning evidenced by
repeated and escalating loss of cognitive or volitional control over his/her actions and is
not receiving such care as is essential for his/her health or safety.
1.9 "Juvenile" means a youth under the chronological age of eighteen years of age arrested on
a Port Orchard warrant or by the City's law enforcement officers for violation of a law for
which confinement of a juvenile is lawful.
I .10 "Partial Bed-Day" means any consecutive period of time of 12 hours or less during which
a Juvenile is in the custody of the Kitsap County Juvenile Detention Facility, which
includes Booking.
SECTION 2 SERVICES
2.1 This Agreement is limited to the detention of juveniles for offenses which are within the
jurisdiction of, and charged within, the Port Orchard Municipal Court under RCW
I 3.040.030( I )(e)(iii).
The County agrees to accept Juveniles for confinement in the Detention Facility and the
City agrees to compensate the County for such services as provided in this Agreement.
The County will provide the Juveniles confined in the Detention Facility with access to the
same education, medical, dental, and other services provided to other juveniles confined in
the Detention Facility as required by law and County policy and procedures.
2.2
2.3
2.4 Juvenile Compliance. All Juveniles confined in the Detention Facili ty shall be subject to
and expected to comply with all Detention Facility rules, including those related to
discipline, emergency, safety and security rules.
Juveniles Exceeding 18 years. Upon the prior written request from the City, the County
may continue to confine the City's Juveniles in the Detention Facility beyond the age of
2.5
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18 years, but in no event older than 2l years of age
2.6 Rieht of Refusal. The Co unty at all times and for all purposes under this Agreement retains
the absolute right in its sole discretion to reject, limit, or revoke the acceptance of any or
all Juvenile(s), or any other person, for confinement in the Detention Facility at any time
and for any reason whatsoever.
2.7 Non-Detention Services. Court services, probation services, or the like, shall continue to
be the sole responsibility of the City and are not subject to this Agreement.
SECTION 3 TERM
This Agreement shall commence on January 1,2019 and terminate on December 31 ,2019, unless
terminated or extended. This Agreement may be extended for additional consecutive one (1) year
periods at the mutual written agreement of the parties, not to exceed a total of Five (5) years.
Neither party has an obligation to extend this Agreement.
SECTION 4 TERMINATION
This Agreement may be terminated by either party, at the mutual convenience of the party, upon
60 days prior written notice to the Contract Representative of the other party. The notice shall
identify the specific plan for accommodating the removal of the Juveniles affected by the
termination. In the event of termination, the City shall at its own expense, transport the Juveniles
from the Detention Facility on or before the effective date of the termination.
SECTION 5 COMPENSATION AND BILLING
Bed-Day Rate/Housing. The City shall pay the County a basic fee of One Hundred Twenty-
Five Dollars ($125.00) per bed-day for every Juvenile confined in the Detention Facility.
5.1
5.2 Partial Bed-Day Rate. The City shall pay the County a partial bed-day fee of $62.50 per
partial bed-day for every Juvenile confined in the Detention Facility.
5.3 Method of Bill County will invoice the City monthly for amounts due the County
under this Agreement for services provided in the previous month. Such fees shall be due
and payable by the City within thirty (30) days from the billing date. Account balances
overdue 30 days or more will be subject to a service charge of lYo per month (l2o/o per
annum). Should collection become necessary, the City shall be responsible for the payment
of all collection costs, including reasonable attorney fees, associated with the collection of
late payments.
Annual Increase. The bed-day and partial bed-day rate shall be increased annually by one
hundred percent (100%) of that percentage increase set forth in the All Urban Consumers
Index (CPI-U) (1982-1984:100) for the Seattle-Tacoma-Bremerton area as is specified by
the Bureau of Labor Statistics, United States Department of Labor for the prior 12-month
period ending in December; provided, however, the increase shall not be more than six
5.4
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percent (6%) of the amount for the prior year.
5.5 Other Costs. The Ci ty shall promptly pay all other costs, including those for Additional
Health Care Services to the County or third parties as provided herein.
PRESENTATION AND ADMISSION
Prior Verification. Prior to presenting a Juvenile for confinement, the City's Representative
shall contact the Detention Facility and obtain verification from the Detention Manager that
the Detention Facility may Admit the Juvenile for confinement and ensure the order
authorizing confinement contains a provision authorizing the Detention Manager to provide
emergency medical treatment to the Juvenile. Prior verification does not guarantee
Admission by the Detention Facility.
6.1
6.2 Presentation. When presenting a Juvenile to the County for confinement, the City
Representative shall remain at the Detention Facility with the Juvenile and comply with all
requirements of this Section and all Detention Facility procedures and rules until the Juvenile
has been admitted.
6.3 Prohibitions
6.4
A. Any Juvenile who is unconscious, under the influence of alcohol and/or drugs (as
determined by Kitsap County), or Gravely Disabled may not be Admitted into the
Detention Facility.
B. Any Juvenile with significant injuries, or who reports that he/she is currently
experiencing significant medical or mental health issues, may be Admitted in the
Detention Facility only when the Juvenile has been medically cleared for confined
Detention by a medical doctor, nurse practitioner, or other equivalent medical personnel,
and approved by Kitsap County.
Certification. The City is at all times solely responsible for determining that all Juveniles
presented by City Representatives to the County for confinement are lawfully detained and
confined, and certifies the same by the act of presenting the Juvenile for confinement to
the Detention Facitity. The City shall defend, indemnify and hold the County harmless as
provided herein for any claim or action resulting from the detention of a Juvenile
wrongfully presented by the City, or its representative, to the County for confinement.
Intake Assessment. When presenting a Juvenile to the Detention Facility for confinement,
the City's Representative shall provide the Detention Facility staff with the following:
A. DuratiorVConditions - provide copies of all records in the possession pertaining to
the Juvenile's confinement, which includes without limitation, all relevant court
orders which identiff the duration and other terms of confinement.
6.5
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SECTION 6
Emergency Medical Treatment - ensure the order of confinement contains
authorization for Director of Kitsap County Juvenile Detention Facility to provide
the Juvenile emergency medical treatment.
C. Intake Assessment -provide all information requested on the Detention Facility
Intake Assessment attached hereto as Exhibit A.
D. Parental Consent edical Treatment ,)- provide a signed copy of the Parental
Consent for Medical Treatment and a copy of any medical insurance coverage
information for the Juvenile in the event the Juvenile requires medical treatment
while in the Detention Facility. See Exhibit B - Parental Consent for Medical
Treatment. The City is and remains responsible for obtaining all consents and
providing medical insurance coverage information.
E.Medical/Mental Health Status - provide a copy of the Juvenile's medical records
in the City's possession and advise the Detention Facility staff of all information
known about a Juvenile's medical and mental health status (current and historical),
including the Juvenile's psycho-sexual history.
Drugs/Alcohol - inform the Detention Facility staff of all information known about
the Juvenile's alcohol and drug usage (current and historical).
G. ADA Acco ons inform the Detention Facility staff of any known
accommodation needs of the Juvenile consistent with the requirements of the
Americans with Disabilities Act.
H. Information -provide all relevant information available regarding the Juvenile and
such other information/documentation routinely required by the Detention Facility.
6.6 Admission. The Ci ty's Representative transporting the Juvenile to the Detention Facility
shall remain at the Detention Facility with the Juvenile until advised by the Detention
Facility staff that the preliminary portion of the booking procedure has been completed and
the Juvenile has been admitted into the Detention Facility.
6.7 Personal Property. Upon Admission of the Juvenile for confinement, County agrees to
accept and store the Juvenile's personal belongings in an amount not to exceed a day pack
or equivalent in volume. Any personal belongings exceeding this amount will require
approval from County. Any personal property not removed from the Detention Facility by
the Juvenile upon the Juvenile's release from the Detention Facility will be deemed to be
abandoned and automatically become the property of the County without the requirement
of further court action.
B
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6.8 Notice. The County will use reasonable efforts to advise the City if a Juvenile is being
detained by another law enfor ement agency on a warrant issued by the City.
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SECTION 7 LEGAL REPRESENTATION. JUVENILE
The City shall be responsible for responding to requests for legal assistance or legal representation
made by the Juvenile confined in the Detention Facility. The County will notify the City of any
requests for legal assistance or legal representation made by a Juvenile to a County detention
officer.
SECTION 8 TRANSFER AND RELEASE
8.1 Release. The Juvenile may be released from confinement from the Detention Facility as
provided below.
A. Request by City. The Juvenile may be released to the City's Representative upon
written direction or verified verbal direction from the City's Representative.
Court Order/Bail. The Juvenile may be released by valid court order or posting of
bail.
Treatment. The Juvenile may be released due to medical, mental health, dental
treatment or any other health care services not available within the Detention
Facility.
Emergency/Catastrophe. The Juvenile may be released in the event of any
emergency or catastrophic condition occurring that poses a reasonably imminent
danger to the safety of the Juvenile or County personnel. The decision to release or
remove persons from the Detention Facility will be at the sole discretion of the
County. In such cases, the County will provide the City reasonable notice of the
removal and shall exercise reasonable care for the safekeeping and custody of the
Juvenile(s) so removed.
8.2 Resumption of Custodv. The City shall be deemed to have resumed custody of the Juvenile
upon the County's presentation of the Juvenile to the City, or upon the City's
Representative taking physical control of the Juvenile.
SECTION 9 TRANSPORTATION AND SECURITY
B
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D
9.1 Transportation. Unless otherwise agreed, the City shall be responsible for all transportation
of Juveniles, which includes the delivery and pickup of the Juveniles for all purposes under
this Agreement.
Release. A City Representative shall be promptly available to pick up the Juvenile when
released from the Detention Facility, regardless of the basis of the release. Promptly
available means immediately available, and in no event longer than four (4) hours after the
City receives notice from the County of the Juvenile's release. Notice forthis purpose may
be a written or oral notice from the Detention Facility to the City.
9.2
9.3 Reimbursement - Transportation/Security. In the event that the County provides the
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transportation, regardless of the reason, the City shall be required to reimburse the County
for all costs of transportation and associated security incurred by the County to secure
emergent medical evaluations, emergency treatment and to support the reasonable necessary
operational needs of the Detention Facility. The cost for transportation and custodial security
time performed by County staff shall be the Internal Revenue Service mileage rate in effect
at the time of the service performed and the current cost to provide a detention officer
(currently $40.14 per officer per hour).
SECTION IO HEATH CARE
10.1 Services Provided. U pon County's Admission of the Juvenile, the County will provide the
Juvenile at no additional charge the routine medical services that are readily available to other
detainees from the County's in-house third-party health care provider for which the health
care provider does not render a separate billing for providing such service to a detainee.
Services for which a separate billing is provided €re considered Additional Health Care
Services.
10.2 Reimbursement. The City shall reimburse County for its proportion of all Additional Health
Care Services and associated costs and expenses in providing such services to a Juvenile.
Reimbursement shall be paid directly to the County or third parties, as directed by the
County.
10.3 Hospitalization.In the event a Juvenile is ho spitalized, the County will advise the City. The
City's Representative will advise the County if the City will be providing the security or
requests the County to do so. If the City is to provide the custodial security, the Juvenile shall
be released to the custody of the City. If the County agrees to provide the custodial security
for the Juvenile, the City shall be responsible for reimbursing the County for all costs
associated with the transportation and custodial security, as provided in Section 9.
10.4 EmergencyA.Jon-emergent Care (outside) Facilitv - Notification. The Co unty will use
reasonable efforts to notiff the City within four (4) business hours of transport (Monday-
Friday, 9am - 5pm) of emergent care for a Juvenile outside the Detention Facility. For non-
emergent care outside of the facility, the County will use reasonable efforts to notiff the
City before noon on the next business day after the transport occurs. Lack of notice will not
relieve the City of its reimbursement obligations to Kitsap County.
10.5 No Waiver of Right to Seek Reimbursement. Nothing in this Agreement shall be construed
to waive the rights of either party to seek reimbursement for costs from the Department of
Social and Health Services, or from the Juvenile, his or her parenVguardian, or any other
responsible third-party.
SECTION 11 INSURANCE AND INDEMNIFICATION
1 I .1 Insurance. The County and City shall maintain, throughout the term of this Agreement,
insurance adequate to protect both parties against claims that may arise as a result of the
performance of this Agreement. Such insurance shall be placed with responsible insurers,
self-insured, or carried through participation in an insurance pool at levels of coverage
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adequate to protect the County and the City against loss, and as ordinarily carried by
municipalities engaged in similar operations. Upon request of the other party, the County
and City shall provide evidence of liability coverage.
ll.2 Indemnification. The City agrees to defend, indemnify and hold harmless the County, its
appointed and elected officials, employees and agents from and against all liability, loss,
cost, damage and expense whatsoever, including costs and attorney's fees in defense thereof
because of actions, claims or lawsuits alleging damages sustained by any person or property
including death at any time resulting thereof, arising from or alleged to have arisen from: D
the City's performance under this Agreement or as a consequence of any wrongful or
negligent acts or omission of the City, its appointed and elected officials, employees and
agents; ii) the wrongful detention of a Juvenile as a result of the City's actions or failure to
act; andlor iii) failure or refusal to timely release a Juvenile as a result of the City's actions
or failure to act.
1 1.3 To the extent the claim, damages, losses and expenses are cause by intentional acts of or by
the concurrent negligence of Kitsap County, its officers, agents, or employees, the City's
indemnification obligation hereunder shall be limited to the City's proportionate share of
liability as agreed to by the parties to this Agreement or determined by a court of competent
jurisdiction.
11.4 Kitsap County agrees to defend, indemnifu and hold harmless the City, its appointed and
elected officials, employees and agents from and against all liability, loss, cost, damage and
expense including costs and attorney's fees in defense thereof because of actions, claims or
lawsuits alleging damages sustained by any person or property including death at any time
resulting thereof, arising from, or alleged to have arisen from: i) Kitsap County's
performance under this Agreement or as a consequence of any wrongful or negligent acts or
omission of Kitsap County, its appointed and elected officials, employees and agents; ii)
wrongful detention of a Juvenile as a result of Kitsap County's actions or failure to act; and/or
iii) Kitsap County's failure or refusal to timely release a Juvenile.
1 1.5 To the extent the claim, damages, losses and expenses are caused by intentional acts of or by
the concurrent negligence of the City, its officers, agents, or employees, Kitsap County's
indemnification obligation hereunder shall be limited to Kitsap County's proportionate share
of liability as agreed to by the parties to this Agreement or determined by a court of
competent j urisdiction.
1 1.6 Solely for the purposes of this indemnification provision, the City expressly waives any
immunity derived from Title 5l (Industrial Insurance) of the Revised Code of Washington
or the City's equivalent thereof, and acknowledges that this waiver was mutually agreed
upon by the parties.
I 1.8 OblieationsAlotice of Cleim.County will provide the City notice of the assertion of liability
by a third party that may give rise to a Claim by County against the City based on the
indemnity contained herein. City shall promptly advise County in writing, which shall in
no event exceed 14 calendar days from the notice date, whether City accepts or denies
tender of the claim. City shall reimburse County for all fees and costs of defense whether
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incurred before or after the notice of claim. City shall keep County timely and fully
informed through all stages of the defense and promptly respond to and comply with
County's requests for information. The County at all times reserves the right, but not the
obligation, to participate in the defense and such participation shall not constitute a waiver
of City's indemnity and defense obligations under the Contract.
SECTION 12 GOVERNING LAW
Governing LawlVenue. The Agreement, and the Juvenile(s) confined under this Agreement, shall
be made under, construed in accordance with, and governed by the laws of the State of
Washington, without regard to conflicts of law or choice of law provisions. Any action arising out
of, related to or in connection with this Agreement shall be instituted and maintained only in a
court of competent jurisdiction in Kitsap County, Washington or as provided by RCW 36.01.050.
SECTION 13 C ONTRACT REPRESENTATIVE S
Unless otherwise provided herein, any required notice will be in writing and deemed given and
received either on the date personally served to the other party's Contract Representative or on the
third day after the date of the postmark of deposit by registered or certified first class U.S. mail,
postage prepaid and properly addressed to the Contract Representative as follows:
County:Michael S. Merringer
Director
Kitsap County Juvenile Department
Kitsap County Juvenile Service Center
1338 SW Old Clifton Road
Port Orchard, WA 98367
City:Geoffrey C. Marti
Chief of Police
Port Orchard Police Department
546 Bay Street
Port Orchard, WA 98366
SECTION 14 NON.DISCzuMINATION
The parties in the performance of this Agreement shall not discriminate against any person on
the basis of race, color, creed, religion, national origin, d1a, sex, marital status, sexual
orientation, veteran status, disability, or other circumstance prohibited by federal, state, or local
law, and shall comply with Title VI of the Civil Rights Act of 1964, P.L. 88 354 and Americans
with Disabilities Act of 1990.
SECTION 15 INDEPENDENT CONTRACTOR
For all purposes, each party will act in its individual capacity and not as an agent, employee,
partner, joint venture, or associate of the other. An employee, agent, or subcontractor of one party
shall not be deemed or construed to be the employee, agent or subcontractor of the other for any
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purpose whatsoever including responsibility for any federal or state tax, industrial insurance or
social security liability.
SECTION 17 ACCESS AND RECORDS
17 .l Access - Detention Facility. The City shall have the right to inspect, at mutually agreeable
times, the Detention Facility in order to confirm the County maintains standards acceptable
to the City and that its detainees are treated appropriately. The County agrees to manage,
maintain and operate its Detention Facility consistent with applicable federal, state and
local laws.
17 .2 Access to Juveniles. City law enforcement shall have the right to interview Juveniles at
any reasonable time within the Detention Facility and the option to use the Detention
Facility interview rooms.
17.3 Records. The County agrees to maintain a system of record keeping relative to the booking
and confinement of each Juvenile consistent with the record keeping by the County for all
other detainees. The County will keep records of all medical, mental health or dental
services it provides to a Juvenile as required by law. The County agrees to share all
information, including insurance information, regarding a Juvenile with the City as
authorized by law.
SECTION 17 GENERAL PROVISIONS
17.l Force Majeure. Neither party shall be in default by reason of any failure in performance of
this Agreement if such failure arises out of causes beyond their reasonable control and
without the fault or negligence of said party including acts of God, terrorism and other acts
of public enemy, war, epidemics or quarantine restrictions.
17 .2 No Waiver. No waiver of any right under this Agreement shall be effective unless made in
writing by an authorized representative of the party to be bound thereby. Failure to insist
upon full perforrnance on any occasion shall not constitute consent to or waiver of any
continuation of nonperfornance or any later nonperforrnance; nor does payment of a
billing or continued perfornance, after notice of a deficiency in performance, constitutes
acquiescence thereto.
17.3 Priority. The Detention Facility policies and rules shall apply for all purposes, unless they
conflict with the terms and conditions of this Agreement. In the event of conflict, this
Agreement will control.
17.4 Modification. No supplement, modification, or amendment of any term of this Agreement
will be deemed binding or effective unless in writing and signed by both parties.
17 .5 Assignment/Delegation. Neither party may assign or delegate its rights, nor its
responsibilities under this Agreement to a third party, without the prior written consent of
the other party. Any purported assignment or delegation in violation of the subsection is
void.
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17.6 Severability. The provisions of this Agreement are severable. Any term or condition of the
Agreement or application thereof deemed to be illegal, invalid or unenforceable, in whole
or in part, shall not affect any other term or condition of the Agreement and the parties'
rights and obligations will be construed and enforced as if the Agreement did not contain
the particular provision.
17 .7 Third Party B eneficiarv . Nothing under this Agreement shall be construed to give any
rights or benefits in the Agreement to anyone other than the County and the City, and all
duties and responsibilities undertaken pursuant to this Agreement will be for the sole and
exclusive benefit of the County and the City, and not for the benefit of any other party.
17.8 No Waiver. Either party's failure to insist on strict performance of any term or condition
of the Agreement shall not be deemed a waiver of that term or condition even if the party
accepting or acquiescing in the nonconforming performance knows of the nature of the
performance and fails to object to it.
17 .9 Entire Asreement. The parties acknowledge that this Agreement is the product of
negotiation between the parties and represents the entire agreement of the parties with
respect to its subject matter. All previous agreements and representations, whether oral or
written, entered into prior to this Agreement are hereby revoked and superseded.
17.10 Provisions uired bv Law. Each and every provision of law and any clause required by
law to be in the Agreement shall be read and enforced as though it were included herein
and if through mistake or otherwise any such provision is not inserted, or is not correctly
inserted, then upon the application of either party the Agreement shall forthwith be
physically amended to make such insertion or correction.
17 .11 Counterparts. This Agreement may be executed by the parties in any number of separate
counterparts, each of which when executed and delivered shall be deemed an original, and
all such counterparts shall together constitute one original document. All signatures need
not be on the same counterpart.
17.12
17.13
Survival. Those provisions of the Agreement that by their sense and purpose should survive
expiration or termination of the Agreement shall so survive such as references to
compensation and indemnification. Those provisions include, but are not limited to,
Sections 5 (Compensation and Billing); 6 (Presentation and Admission); 9 (Transportation
and Security); 10 (Health Care); 11 (Insurance and Indemnification); 12 (Governing Law);
15 (Independent Contractor) and 17 (General Provisions).
Authorization. Any authorizations, actions required, or pernitted to be taken, and any
document required or permitted to be executed under this Agreement will be taken or
executed only by a duly authorized representative of the party. Each party warrants and
represents to the other that the person signing below has been properly authorized and
empowered to execute this Agreement on behalf of the Party for whom they sign.
Pagelll
Approved and executed this day of
CITY OF PORT ORCHARD
!r,<- zulg-?otYri..-
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Robert B.
ATTEST:
ATTEST:
Dana
Clerk of the Board
Mayor
CI
Approved and executed this day of Jnrru R'c\ zotg
BOARD OF COTINTY COMMISSIONERS
KITSAP COUNTY, WASHINGTON
EDWARD E.OLFE, Chair
C OTTE GARRIDO, Commissioner
ROBERT G LDER, Commissioner
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EXHIBIT A
DETENTION FACILITY INTAKE ASSESSMENT
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HEALTH SERVICES INTAKE SCREENING FORM
Examiner's Observations
Screen ng Offl
Date Time:
Juvenile Name:Age:
Legal Guardian:Phone:
Address:
DOB:Sex:POB:Ethnicity:JCS #:
Hgt:wgt:Hain Eyes
Yes No1Unconscious
Yes NoV sible signs of trauma or illness requir ng emergency medical care
Describe:
Yes No3Obvious fever, swol en glands, jaund ce or evidence of infection,
Describe:
No4Evidence of cough, coughing up blood, weight loss or night sweats.
Describe:
Yes No5Poor sk n condition, rash, vermin or need e marks.
Descrlbe:
Yes No6.Under the influence of a cohol, or other mind-altering drugs, including inhalants (within
the past 6 hours).
Describe:
Yes No7Vlslble signs of ETOH or drug withdrawe , .€. extreme perspiration, pinpo nt pupils,
shakes, nausea, vomiting or cramping.
Describe:
Yes NoIBehavior suggesting su cide or assault, i.e. withdrawn, suicidal thoughts, or aggressive
behavior.
Describe:
Yes No9.Carrylng medlcatlon or reporting be ng on medication:
List:
With you: Yf, N E
Yes No10.Visible signs of physical deformity. (Scars/MarksfTattoos:)
Describe:
Yes NoA lergies
Describe:
11.
Yes NoHave you had a recent head injury?
Describe:
12.
NoYesUnder the care ofa Phys c an?
W th who:For what:
13.
Yes No14.Females: Are you currently pregnant?
Date of last Menstrual Cyc e:Method of birth Control:
15.Temperature:
DO#
2.
Yes
Updated l0l24ll8 I
EXHIBIT B
PARENTAL CONSENT FOR MEDICAL TREATMENT
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KITSAP COUNTY JUVENILE DETENTION CENTER
HEAL]'H SERVICES
Parental Consent for Medical Treatment
I, , parent/legalguardian of .a
detainee at the Kitsap County JuvenilE DEtention facility (KCJDF), do hereby give my consent for th€ routine and/or emergency medical or
dental cart and/or immunizations, as deemed necessary by the Health SeNices staffor the Detention Specialist staff.
-In the event my child develops a medical or dental problem beyond the oapabilities of the KCJDF Health Services, I authorize the medical or
dental facility, th€ medical or dental provider to which my child is refened, to evaluate and treat as indicated.
{ further authorize the medical or dental facility; the medical or dental provider to release such information as may be needed for the
cohpletion ofhospital claims, to any insur€r or to the KCIDF and Health Services for the d€t€rmination offollow-up treatment.
-l also agree to be financially responsible for any and all medical and dental care, including prcsctiptions that may be nec€ssary for my child.
-l further authorize the KCIDF staff, under the dtection ofthe Health Services staff; to administer any approved prescription or over-the-
counter medications, lo my child pursuant to the prescribed medical indications and directions on the container. All approved medications
given my child shall be appropriately recorded.
-Emergency medical care will bc provided at Kaiser Permanente in Port Orchard, at CHt Franciscan H€alth Urgent Carc Clinic, Port Orchard,
the Emergency Room, Harrison Medical Center, Bremerton, or the Emergency Room, Naval Hospital, Br€melton, (dopendent upon acuteness,
urgency and eligibitity for care), unless otherwise specified.
Our farnily phys ician is (Name)(Phone#)and, if
possible, should be notified in order to prcvide emergenry and continuing medical care for my child.
Tbis authorization is yalid from this date of this authorizatiotr until the mitror has completed all detention timc under thb Cause
Number as ordered the Cou or until the minor has reached the a of consent.
(lf possible, please attach a photocopy of the coupon or insurance card.)
Parent / Guardian i Other Date Tirne
DO#
Detention Officef/Probation offic€r Date Time
VERBAL Consent
Verbal consent given by , parent or legal guardian ofnamedjuvenile
[91the medical or dental care listed above by telephone conference with the Detention lntake Officcr.
(Two Detentlon Oflicers' signatures are rGquired when receiving verbal mcdical consent)
Detention Officer #l DO#Date:Time:
Detention Officer #2 DO#Date: Time:
Comments:
.Notify parents:HIPPA riqhts notification is "on-line" on the Juveni le Department's webpaoe or thev rnav request a
Medical
Insurance
Contract
Number
Group
Number
p{n$e-C, copv.
Are there any medical problems your child is being treated for?Yes No
lf yes, describe;
ls your child taking any medication?Yes No
lf yes, describe;
ls there any important information we should know about your child?Yes No
lf yes, describe;
Does your child have any food/drug allergies or require any special needs while in detention?
lf yes, descrlbe;
Have visitation times and procedure been explained?
Has court time and/or probable cause weekend procedure been
explained?
Yes
Yes
No
No
ls the child in special education or does the child have an IEP (lndividual Education Plan) at school?
Does the child receive SSI (Supplemental Security lncome)?
Does the Child have a DDD (Division of Developmental Disabilities) Case Manager?
Yes
Yes
Yes
No
No
No
Case Manag,
Updated 10/24/18
ers name:
-2-