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Exhibit A <br />Statement of Work <br />Contract Term: 2015-2017 <br />DOH Program Name or Title: Maternal & Child Health Block Grant- <br />Effective January 1, 2015 <br />SOW Type: Original Revision # (for this SOW) <br />Period of Performance: Januarv 1. 2015 through September 30, 2015 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: Cl7114 <br />Funding Source Federal Compliance Type of Payment <br />cg] Federal Subrecipient (check if applicable) t2I Reimbursement o State rgr FF A T A (Transparency Act) o Fixed Price o Other o Research & Development <br />Statement of Work Purpose: The purpose of this statement of work is to support local interventions that impact the target population of the Maternal and Child Health Block <br />Grant. <br />Revision Purpose: NI A <br />Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change T otal <br />Revenue Index (LHJ Use Only) Consideration Increase (+) Con sideratioo <br />Code Code Start Date End Date <br />FFY15 MCHBG CBP ConCon 93.994 333.93.99 78734250 01101115 I 09/30/15 0 33.147 33;147 <br />~'fALS_ ------------.L ---'!.I _ 33,1 47 <br />- <br />33.1 47 <br />... c h' -~--------------------for all federally funded sub f -----------------------.------ <br />CFDA# CFDA Program Title I Federal Grant Award # Federal Grant Award Name Federal Agency Name <br />93.994 Maternal and Child Health I lB04MC26703-xx-xx Maternal and Child Health Block Grant JlHHS-HRSA <br />------ <br />Task *May Support PHAB Payment <br />Number Task! ActivitylDescription StandardsIMeasures Deliverables/Outcomes Due Date/Time Frame Information and/or <br />Amount <br />Maternal and Child Health Block Grant (MCHBG) Administration <br />la Participate in calls, at a minimum of every other Designated LHJ staff will September 30,2015 Reimbursement for <br />month, with DOH contract manager. Dates and participate in contract actual costs, not to <br />time for calls are mutually agreed upon between management calls. exceed total funding <br />DOHandLHJ . consideration. Action <br />Ib Participate in DOH sponsored MCHBG-related Designated LHJ staff'will September 30,2015 Plan and Progress <br />quarterly conference calls and/or webinars, participate in calls, webinars, and Reports must only <br />incloding u p to two (2) in -person me etinM. meetings. reflect activities paid <br />Ic Complete 2015-2016 MCHBG Budget Workbook Submit completed MCHBG September 4,2015 for with funds <br />for October 1,2015 through September 30,2016 Budget Workbook to DOH provided in this <br />using DOH provided template. contract manager. statement of work for <br />Exhibit A, Statements of Work Page 5 of 19 Contract Number C 17114