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CONTRACT PROVIDER NAME: KAH,L.L.C.dba Right at Home <br /> CONTRACT NUMBER: 68-1020 <br /> CONTRACT PERIOD: April 1,2014-June 30,2014 <br /> PROVIDER'S FISCAL YEAR:July 1,2013-June 30,2014 <br /> CONTRACT DETERMINATION QUESTIONNAIRE <br /> (PURCHASE OF SERVICE VS.FINANCIAL ASSISTANCE) <br /> Please place a X in the box under either the YES or NO column for each question. <br /> For definitions of"key terms"for each question,please see the instructions worksheet. <br /> Additional space is provided at the bottom of the form if needed. <br /> Yes No <br /> 1. Does the contract Provider determine client eligibility'! 0 in <br /> Comments: <br /> Z. Does the contract Provider authorize services on a client specitic basis'! <br /> Comments: 13 E3 <br /> 3. Does the contract Provider determine the appropriateness <br /> of the services to be provided? <br /> Comments: <br /> 4. Does the contract Provider provide programmatic functions <br /> for the contract,such as: <br /> a. Program evaluation? <br /> Comments: <br /> b. Program planning? C1 El <br /> Comments: <br /> c. Monitoring'! <br /> Comments: 13 El <br /> d. Develop program standards,procedures,and rules'! <br /> Comments: <br /> 5. Does the contract Provider have responsibility for program compliance'! a <br /> Comments: El <br /> 6. Does the contract Provider have to submit a cost report to satisty <br /> a cost reimbursement arrangement? <br /> Comments: <br /> 7. Does the contract Provider have any obligation to the funding <br /> authority other than the delivery of the specified goods/services? E3 Im <br /> Comments: <br /> 8. Does the contract Provider operate in a competitive environment'! <br /> Comments: El El <br /> 9. Does the contract Provider provide similar goods and/or <br /> services to many different purchasers? <br /> Comments: <br /> 10. Does the contract Provider provide the goods and/or services 0 <br /> within normal business operations? <br /> Comments: <br /> X inside the gray boxes may indicate a Purchase of Service Contract. <br /> X inside the clear boxes may indicate a Financial Assistance Contract. <br /> NOTE: The authorized individual(s)must place a check mark in one of the boxes below to indicate <br /> the type of contractual arrangement for this contract,then sign and date where indicated. <br /> PURCHASE OF SERVICE FINANCIAL ASSISTANCE <br /> Signature of Authorized Programatic Indiviudal Date <br /> Signature of Authorized Administrative Individual Date <br />