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Exhibit A <br />Statement of Work <br />Contract Term: 2015-2017 <br />DOH Program Name or Title: Office ofImmunization & Child Profile - <br />Effective January 1. 2015 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: C 17114 <br />SOW Type: Original Revision # (for tbis SOW) Funding Source Federal Compliance Type of Payment <br />t8I Federal Subrecipient (check ifapplicable) t8I Reimbursement o State IZI FF ATA (Transparency Act) o Fixed Price o Other o Research & Development <br />Period of Performance: January 1. 2015 through December 31. 201 5 <br />Statement of Work Purpose: The purpose of this statement of work is to define required immunization tasks , deliverables, and funding. <br />Revision Purpose: NI A <br />Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change [rotal <br />Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration <br />Code Code Start Date End Date <br />FFY15 VFC Ops 93 .268 333.93.26 74203250 OliO 1/15 12/31115 0 1,129 1,129 <br />FFY 15 VFC Ordering 93 .268 333.93.26 74204250 01101115 12/31 /15 0 1,154 1,154 <br />FFYI5 317 Ops 93.268 333 .93.26 74201250 01/01115 12/31/15 0 1.260 1,260 <br />FFY15 AFIX 93.268 333 .93.26 74205250 01 /01115 12 /31115 0 5,013 5.013 <br />TOTALS 0 8.556 8.556 <br />Task *May Support PHAB Payment <br />Task! Activity /Description Deliverables/Outcomes Due Daterrime Frame Information andlor Number StandardslMeasures Amount <br />Perfonn 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 enrollment <br />vi si ts, fraud and abuse re po rr rng, monthl)' aC COUI1t;ib ility reports., and privat e provider re:>o r! of vaccine usage. <br />1 Facilitate annual renewal of the Provider Provider Agreements for Receipt Annually, per Annual Reimbursement for <br />Agreement for Receipt of State Supplied of State Supplied Vaccine received VFC Provider Agreement actual costs incurred, <br />Vaccine for all health care providers receiving online via the Washington Update Schedule not to exceed total <br />state-supplied childhood vaccines, per Immunization Infonnation System. funding consideration <br />instructions at this link amount. <br />Funds available for <br />this task*: <br />FFY15 AFIX, <br />74205250 <br />---~ <br />Exhibit A, Statements of Work Page 14 of 19 Contract Number CI7114 <br />,