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Task <br />Number Task! Activity/Description <br />3c Develop 2016-2017 MCHBG Action Plan for <br />October 1, 2016 through September 30 , 2017 <br />using DOH-provided template. <br />3d Report activities and outcomes of2015-2016 <br />MCHBG Action Plan using DOH-provided <br />template . <br />3e Develop 2017-2018 MCHBG Action Plan for <br />October 1, 2017 through September 30 , 2018 <br />usin g DOH-provided template. <br />3f Report activitie s and outcomes of2016-2017 <br />MCHBG Action Plan using DOH-provided <br />template . <br />Children with Special Health Care Needs (CSHCN) <br />4a Complete Child Health Intake Form (CHIF) using <br />the CHIF Automated System on all infants and <br />children served by the CSHCN Program as <br />referenced in CSHCN Program Manual. <br />Exhibit A, Statement s of Work <br />Revised as of November 15 ,2016 <br />*May Support PHAB <br />StandardslMeasures Deliverables/Outcomes <br />Submit MCHBG Action Plan to <br />DOH contract manager. <br />Submit Action Plan quarterly <br />reports to DOH contract manager, <br />Submit MCHBG Action Plan to <br />DOH contract manager. <br />Submit Action Plan quarterly <br />reports to DOH contract manager. <br />Submit CHIF data into Secure <br />File Transport (SFT) website: <br />https:lfsft.Wa.20V <br />I <br />Page 5 of21 <br />AMENDMENT #10 <br />Payment <br />Due DateITime Frame Information and/or <br />Amount <br />If LHJ chooses to bill on a the specified funding <br />monthly basis , reports are period. <br />due on or before the 15 th See Program Specific <br />of the followin g month. Requirements and <br />Draft-August 19 ,2016 Special Billing <br />Final-September 2 ,2016 Requirements . <br />January 15 ,2016 <br />April 15 , 2016 <br />July 15 ,2016 <br />October 15,2016 <br />IfLHJ chooses to bill on a <br />monthly basis , reports are <br />due on or before the 15 th <br />of the followin g month. <br />Draft-August 18 , 2017 <br />Final-September 1,2017 <br />January 15 ,2017 <br />April 15 , 2017 <br />July 15 ,2017 <br />~f-bI4J eheeoe!i 19 bill on (J <br />I/i(J~I~hl}' he5'i'~, 1't1fJ9>",ftj fiFi3 <br />dtJe (m oF-h<.1ere-tlte-J-}-III <br />.. ,t, r _ . <br />January 15 ,2015 Reimbursement for <br />April 15 , 2015 actual costs , not to <br />July 15 ,2015 exceed total funding <br />October 15 ,2015 consideration. Action <br />January 15 ,2016 Plan and Progress <br />April 15, 2016 Reports must only <br />July 15,2016 reflect activities paid <br />October 15 ,2016 for with funds <br />January 15 ,2017 provided in this <br />April 15 , 2017 statement of work for <br />July 15 ,2017 the specified fundin g <br />Contract Number C 17114-1 0