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Exhibit A <br />Statement of Work <br />Contract Term: 2015-2017 <br />AMENDMENT #5 <br />DOH Program Name or Title: Office of Immunization & Child Profile - <br />Effective January I, 2016 <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 />~ Federal Subrecipient (check if applicable) ~ Reimbursement <br />D State ~ FFATA (Transparency Act) D Fixed Price <br />D Other D Research & Development <br />Period of Performance: January 1, 2016 through December 31, 2016 <br />Statement of Work Purpose: The purpose of this statement of work is to define required immunization tasks, deliverables, and funding. <br />Revision Purpose: N/ A <br />Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total <br />Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration <br />Code Code Start Date End Date <br />FFY 16 VFC Ops 93.268 333.93.26 74110263 01/01116 12/31116 0 828 828 <br />FFY 16 VFC Ordering 93.268 333.93.26 74110264 01/01/16 12/31116 0 1,400 1,400 <br />FFY16 317 OPS 93.268 333.93.26 74110261 01/01116 12/31116 0 1,232 1,232 <br />FFY16 AFIX 93.268 333.93.26 74110265 01/01116 12/31116 0 4,293 4,293 <br />TOTALS 0 7,753 7,753 <br />Task *May Support PRAB Payment <br />Task! Activity /Description Deliverables/Outcomes Due Date/Time Frame Information and/or Number StandardslMeasures Amount <br />Perform accountability activities in accordance with state and federal requirements for the Vaccines for Children (VFC) Program as outlined in the Centers for Disease Control and <br />Prevention (CDC) VFC Operations Guide and as directed by the state administrators of the VFC program. Accountability requirements include, but are not limited to: provider <br />education, provider site visits and required corrective action, quality assurance activities, VFC screening, satisfaction survey, outside provider agreements, new provider <br />enrollment visits, fraud and abuse reporting, monthly accountability reports, and private provider report of vaccine usage. <br />1 Facilitate annual renewal of the provider <br />agreement for receipt of state supplied vaccine <br />for all healthcare providers receiving state- <br />supplied childhood vaccines <br />Exhibit A, Statements of Work <br />Revised as of November 16,2015 <br />Provider Agreements for Receipt of <br />State Supplied Vaccine received <br />online via the Washington <br />Immunization Information System <br />(WA lIS). <br />Page 3 of 10 <br />Annually, per Annual Reimbursement for <br />VFC Provider Agreement actual costs incurred, <br />Update Schedule not to exceed total <br />funding consideration <br />amount. <br />Funds available for <br />this task*: <br />FFY16 AFIX, <br />74110265 <br />Contract Number C 17114-5