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Exhibit A <br />Statement of Work <br />Contract Term: 2015-2017 <br />AMENDMENT #5 <br />DOH Program Name or Title: OICP-Prevention & Public Health Funds (PPHF) <br />VTrckS-IIS -Effective December 1, 2015 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: C17114 <br />SOW Type: Original Revision # (for this SOW) Funding Source Federal Compliance Type of Payment <br />[8J Federal Subrecipient (check if applicable) [8J Reimbursement <br />D State [8J FF A T A (Transparency Act) D Fixed Price <br />D Other D Research & Development <br />Period of Performance: December 1, 2015 through August 31, 2016 <br />Statement of Work Purpose: The purpose of this statement of work is to provide funding to local public health to provide support and technical assistance to health care providers <br />using the Immunization Information System (US) to conduct vaccine management-related activities. <br />Revision Purpose: N/ A <br />Chart of Accounts Program Name or Title <br />FFY14 Enhance IIS and VTrckS <br />TOTALS <br />Task <br />Number Task! Activity/Description <br />I Provide outreach, education, support, and training <br />to providers during the implementation of <br />Immunization Information System (liS) <br />enhancements and development of new liS <br />functionality. This includes: <br />• Participating in web cast and conference calls <br />conducted by DOH Office of Immunization <br />and Child Profile (OICP) on liS <br />enhancements and new lIS functionality as <br />they are developed and implemented; <br />• Providing training (in-person, online, <br />telephone, fax, or other), support, and <br />technical assistance to providers on liS <br />functionality and quality assurance tools; <br />• Monitoring provider adoption and use of <br />enhanced and new lIS tools <br />Exhibit A, Statements of Work <br />Revised as of November 16, 2015 <br />CFDA# BARS Master Funding Period <br />Revenue Index (LHJ Use Only) <br />Code Code Start Date End Date <br />93.733 333 .93.73 74110241 12/01115 I 08/31116 <br />*May Support PHAB <br />Standards/Measures Deliverables/Outcomes <br />1. Submit the Immunization <br />Information System Vaccine <br />Management Enhancement Project <br />Report (DOH 348-525) for the <br />reporting period: <br />December 1, 20 15-March 31, 2016 <br />2. Submit the Immunization <br />Information System Vaccine <br />Management Enhancement Project <br />Report (DOH 348-525) for the <br />reporting period: <br />April 1, 20 I 6-July 31, 2016 <br />Page 9 of 10 <br />Current Change Total <br />Consideration Increase (+) Consideration <br />0 1,087 1,087 <br />0 !~087 1,087 <br />Payment <br />Due Date/Time Frame Information and/or <br />Amount <br />1. April 15,2016 Reimbursement for <br />actual costs incurred, <br />not to exceed total <br />funding consideration <br />amount <br />Funds available for <br />2. August 15,2016 this task: <br />FFY14 Enhance liS <br />and VTrckS <br />74110241 <br />------- <br />Contract Number C 171 14-5