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DOH Program Name or Title: Maternal & Child Health Block Grant- <br />Effective January 1, 2015 <br />SOW Type: Revision Revision # (for this SOW) 4 <br />Period of Performance: January 1, 2015 through December 31, 2017 <br />Exhibit A <br />Statement of Work <br />Contract Term: 2015-2017 <br />AMENDMENT #14 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: C 17114 <br />Funding Source Federal Compliance Type of Payment <br />~ Federal Subrecipient (check if applicable) ~ Reimbursement <br />D State ~ FFATA (Transparency Act) D Fixed Price <br />D Other D 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: The purpose of this revision is to extend the period of performance from September 30, 2017 to December 31, 2017 , provide additional funding and add and <br />revise tasks and deliverable due dates for continuation of MCHBG related activities. <br />Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period <br />Revenue Index (LHJ Use Only) <br />Code Code Start Date End Date <br />FFY15 MCHBG CBP CONCON 93 .994 333 .93 .99 78734250 01101115 09 /30115 <br />FFY16 MCHBG LHJ & OTHER CONTRACTS 93.994 333 .93 .99 78730260 10/01115 09/30/16 <br />FFY17 MCHBG LHJ & OTHER CONTRACTS 93.994 333 .93.99 78730270 10/01116 09/30/17 <br />FFY18 MCHBG LHJ CONTRACTS 93 .994 333 .93 .99 78120281 10/01117 12 /31117 <br />TOTALS <br />----- <br />Task *May Support PHAB <br />Number Task! ActivitylDescription StandardslMeasures Deliverables/Outcomes <br />Maternal and Child Health Block Grant (MCHBG) Administration <br />la Participate in calls, at a minimum of every eIheF Designated LHJ staff will <br />menth quarter, with DOH contract manager. participate in contract <br />Dates and time for calls are mutually agreed upon management calls. <br />between DOH and LHJ. <br />Ib Participate in DOH sponsored MCHBG-related Designated LHJ staff will <br />quarterly conference calls and/or webinars, participate in calls, webinars, and <br />including up to two (2) in-person meetings. meetings. <br />lc Complete 2015-2016 MCHBG Budget Workbook Submit completed MCHBG <br />for October 1,2015 through September 30 ,2016 Budget Workbook to DOH <br />using DOH provided template . contract manager. <br />----- <br />Exhibit A, Statements of Work <br />Revised as of September 15 , 2017 <br />Page 6 of 10 <br />Current Change Total <br />Consideration Increase (+) Consideration <br />34,870 0 34 ,870 <br />44,196 0 44 ,196 <br />44 ,196 0 44 ,196 <br />0 11 ,049 11,049 <br />123 ,262 11,049 134,311 <br />Payment <br />Due DatelTime Frame Information and/or <br />Amount <br />S~t}HtJ Reimbursement for <br />December 31 , 20 17 actual costs , not to <br />exceed total funding <br />consideration. Action <br />&pwmhe."30 Plan and Progress <br />December 31 , 2017 Reports must only <br />reflect activities paid <br />September 4,2015 for with funds <br />provided in this <br />statement of work for <br />Contract Number C17114-14