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DOH Program Name or Title: Maternal & Child Health Block Grant- <br />~ffective January 1, 2018 <br />SOW Type: Original Revision # (for this SOW) <br />Period of Performance: January 1, 2018 through September 30, 2018 <br />Exhibit A <br />Statement of Work <br />Contract Term: 2018-2020 <br />Local Health Jurisdiction Name: Kittitas Countv Public Health Denartment <br />Contract Number: CLH18249 <br />Funding Source Federal Compliance Type of Payment <br />~ Federal Subrecipient (check if applicable) rgJ Reimbursement o State rgJ FFATA (Transparency Act) o Fixed Price o Other o 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: 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 />FFY18 MCHBG LHJ CONTRACTS 93.994 333.93.99 78120281 01101118 I 09/30/18 0 33,147 33,147 <br />TOTALS 0 33,147 33,147 <br />Task *May Support PHAB Payment <br />Number Task! ActivitylDescription StandardslMeasures Deliverables/Outcomes Due Date/Time Frame Information and/or <br />Amount <br />Maternal and Child Health Block Grant (MCHBG) Administration <br />1a Participate in calls, at a minimum of every Designated LHJ staff will September 30,2018 Reimbursement for <br />quarter, with DOH contract manager. Dates and participate in contract management actual costs, not to <br />time for calls are mutually agreed upon between calls. exceed total funding <br />DOHandLHJ consideration. <br />Ib Report actual expenditures for October 1, 2017 Submit actual expenditures using May 26,2018 Action Plan and <br />through March 31, 2018 the MCHBG Budget Workbook to Progress Reports <br />DOH contract manager must only reflect <br />1c Develop 2018-2019 MCHBG Budget Workbook Submit MCHBG Budget September 5,2018 activities paid for <br />for October 1,2018 through September 30,2019 Workbook to DOH contract with funds provided <br />using DOH provided template. manager in this statement of <br />work for the <br />specified funding <br />period. <br />See Program <br />Exhibit A, Statements of Work Page 2 of28 Contract Number CLH18249