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,- <br />Task <br />Number Task! ActivitylDescription <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 />using DOH~provided template . <br />3f Report activities and outcomes of2016-2017 <br />MCHBG Action Plan using DOH-provided <br />template. <br />3g Report activities and outcomes of2017-18 <br />MCHBG Action Plan for October 1,2017 <br />through December 31,2017 <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, Statements of Work <br />Revised as of September 15, 2017 <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 Action Plan monthly <br />reports to DOH contract <br />manager. <br />Submit CHIF data into Secure <br />File Transport (SFT) website: <br />https :llsft.wa.go v <br />Page 8 of 10 <br />AMENDMENT #14 <br />Payment <br />Due Date/Time Frame Information and/or <br />Amount <br />October 15 ,2015 reflect activities paid <br />for with funds <br />If LHJ chooses to bill on a provided in this <br />monthly basis, reports are statement of work for <br />due on or before the 15 th the specified funding <br />of the following month. period. <br />Draft-August 19, 2016 See Program Specific <br />Final-September 2,2016 Requirements and <br />Special Billing <br />January 15,2016 Requirements. <br />Apri115,2016 <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 following month. <br />Draft-August 18,2017 <br />Final-September 1, 2017 <br />January 15 , 2017 I <br />April 15, 2017 <br />July 15, 2017 <br />Monthly, on or before the <br />15th of the following <br />month . <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 funding <br />Octob er 15, 2017 period. <br />Contract Number C 17114-14