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DOH Program Name or Title: Office ofImmunization & Child Profile - <br />Effective January I. 2017 <br />SOW Type: Original Revision # (for this SOW) <br />Period of Performance: January 1, 2017 through December 31, 2017 <br />Exhibit A <br />Statement of Work <br />Contract Term: 2015-2017 <br />AMENDMENT #10 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: C17114 <br />Funding Source Federal Compliance Type of Payment <br />[8] Federal Subrecipient (check if applicable) [8] Reimbursement o State [8] 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 define required immunization tasks, deliverables, and funding. The period of performance for this <br />statement of work is divided into two funding allocation periods, January through March 2017 and April through December 2017. Tasks and deliverables will be divided <br />proportionately between the two funding periods. <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 />FFYI6 PPHF 317 Ops 93.539 333 .93 .53 74110267 01101117 03 /31117 0 1,805 1,805 <br />FFY 17 VFC Ops 93.268 333 .93.26 74110273 04/0111 7 12/31117 0 1,150 1,150 <br />FFY 17 VFC Ordering 93.268 333.93.26 74110274 04 /01117 12/31117 0 695 695 <br />FFY 17 317 Ops 93.268 333.93.26 74110271 04/01117 12/31117 0 924 924 <br />FFY17 AFIX 93.268 333.93.26 74110275 04 /01117 12/31117 0 3,340 3,340 <br />TOTALS 0 7,914 7,914 <br />- <br />Task Task! Activity/Description *May Support PHAB Deliverables/Outcomes Due Date/Time Frame Payment Information I <br />Number StandardslMeasures and/or 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 15,2016 <br />Ii <br />Provider Agreements for <br />Receipt of State Supplied <br />Vaccine received online via <br />the Washington Immunization <br />Information System. <br />- <br />Page 15 of21 <br />Annually, per Annual VFC Reimbursement for <br />Provider Agreement Update actual costs incurred, <br />Schedule not to exceed total <br />funding consideration <br />amount. <br />Funds available for <br />this task*: <br />Contract Number C 17114-10 <br />!