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Exhibit A <br />Statement of Work <br />Contract Term: 2018-2020 <br />AMENDMENT #1 <br />DOH Program Name or Title: C hildhood Lead P oisoning Preventio n Frogram - <br />Effective January 1, 2018 <br />Local Health Jurisdiction Name: Ki ttitas Coun.!V P ubl ic He a lth Dcoartmeot <br />Contract Number: CLH18249 <br />SOW Type: Original Revision # (for t his SOW) Funding Source Federal Compliance Type of Payment o Federal <Select One> (check if applicable) ~ Reimbursement <br />18l State o FFATA (Transparency Act) D Fixed Price o Other o Research & Development <br />Period of Performance: January 1, 2018 through June 30, 2018 <br />Statement of Work Purpose: The purpose of this statement of work is to support local interventions with the case management of elevated blood lead levels in children 14 years <br />of age and younger. The focus of this program in 2018 is to build local capacity statewide to provide standard case management services to all children with elevated blood lead <br />levels. <br />Revision Purpose: NI A <br />Chart of Accounts Program Name or Title C F DA# BARS Master Funding Period Current Change :rotal <br />Revenue Index (LHJ Use Only) Consideration Increase (+) ~onsideration <br />Code Code Start Date End Date <br />SFYI Lead Environments of Children (proviso funds) N/A 334.04.93 25715110 01101118 I 06 /30118 0 2,000 2,000 <br />TOTALS <br />----~ - <br />Task Task! ActivitylDescription Number <br />1 Contact the provider to gather complete information on the <br />assigned elevated blood lead case to conduct an <br />environmental assessment <br />a) Verify the blood lead level (BLL) is confirmed. <br />Reference Centers for Disease Control and <br />Prevention's (CDC's) confirmed case definition: <br />ht!:Qs :ll wWWn.cdc.Mvl nndsslconditionsllead-elevated- <br />blood-level~case-definition120 161 <br />b) Call family and schedule a home visit <br />c) Visit the child's residence (or other sites where the <br />child spends significant amounts oftime) at least once <br />d) Interview the caregivers using the Child Blood Lead <br />Investigation Form and conduct an environmental <br />assessment to identify factors that may impact the <br />child's blood lead level <br />e) Determine if the family lives in Section 8 or HUD <br />Exhibit A, Statements of Work <br />Revised as ofJanuary 16, 2018 <br />-- <br />*May Support PHAB <br />StandardslMeasures <br />Page 3 of6 <br />0 2,000 2,000 - <br />Payment <br />Deliverables/Outcomes Due Date/Time Information <br />Frame and/or <br />Amount <br />Submit the completed Monthly, by the $500 per home <br />Child Blood Lead Investigation Foon 30th of the visit, up to two <br />available through W A DOH following month (2) home visits <br />indicating : per child <br />a) Confirmed BLL <br />b) Date LHJ contacted the family <br />c) Date the environmental <br />assessment was completed <br />d) Date the interview was <br />completed <br />e) Specify if the home is Section 8 <br />or HUD Housing and if the <br />child is Medicaid enrolled <br />f) (If applicable) If DOH <br />assistance is requested , list the <br />DOH contact and date contacted <br />Contract Number CLH18249-1