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DOH Program Name or Title: Office oflmmunization & Child Profile - <br />Effective January 1, 2017 <br />SOW Type: Revision Revision # (for this SOW) 1 <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 # 11 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: C17114 <br />Funding Source Federal Compliance Type of Payment <br />[gI Federal Subrecipient (check if applicable) [gI Reimbursement o State [gI 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: The purpose of this revision is to add a new task and funding. <br />Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change ifotal <br />Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration <br />Code Code Start Date End Date <br />FFY16 PPHF 317 Ops 93.539 333.93.53 74110267 01101117 03 /31117 1,805 0 1,805 <br />FFY 17 VFC Op~ 93.268 333.93.26 74110273 04/01117 12/31117 U50 0 1,150 <br />FFY 17 VFC Ordering 93.268 333.93.26 74110274 04/01117 12/31117 695 0 695 <br />FFY17 317 Ops 93.268 333.93.26 74110271 04/01117 12/31117 924 0 924 <br />FFY17 AFIX 93.268 333.93.26 74110275 04/01117 12/31117 3,340 0 3,340 <br />FFY15 PPHF IIS AFIX 93.733 333.93.73 74110257 04/01117 04/30/17 0 1,000 1,000 <br />TOTALS I 7,914 1,000 8,914 <br />- <br />Task Task! ActivitylDescription *May Support PHAB Deliverables/Outcomes Due Date/Time Frame Payment Information <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 />emollment 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 March 15,2017 <br />Provider Agreements for <br />Receipt of State Supplied <br />Vaccine received online via <br />the Washington Immunization <br />Information System. <br />Page 8 of 17 <br />Annually, per Annual VFC Reimbursement for <br />Provider Agreement actual costs incurred, <br />Update Schedule not to exceed total <br />funding consideration <br />amount. <br />Funds available for this <br />task*: <br />Contract Number C17114-11