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AMENDMENT #2 Task *May Support PHAB Payment Number Task/Activity/Description Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or Amount Children with Special Health Care Needs (CSHCN) 4a Complete Child Health Intake Form (CHIF) Submit CHIF data into Secure File January 15 , 2018 Reimbursement for using the CHIF Automated System on all infants Transport (SFT) website: April 15, 2018 actual costs, not to and children served by the CSHCN Program as https://sft. wa.gov July 15 , 2018 exceed total funding referenced in CSHCN Program Manual. consideration. Ensure client data is collected on all children Action Plan and served by CSHCN contractors, including Progress Reports neurodevelopmental centers, regional must only reflect maxillofacial coordinators, and the DOH activities paid for Newborn Screening Program. with funds provided 4b Administer requested DOH Diagnostic and Submit completed Health Services 30 days after forms are in this statement of Treatment funds for infants and children per Authorization forms and Central completed. work for the CSHCN Program Manual when funds are used . Treatment Fund requests directly specified funding to the CSHCN Pro_gram as needed. period. 4c Participate in the CSHCN Regional System and Submit Action Plan monthly Monthly, on or before quarterly meetings as described in the CSHCN reports including number of the 15 th of the following See Program Program Manual. regional meetings attended to the month Specific DOH contract manager. Requirements and Special Billing Requirements. *For Information Only: Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: bnp J/www.phaooard .org/wo-cop 1en rl up'loads/P H AB-Standards-and-Measures-Versie n-1 . 0: pdj: Program Specific Requirements/Narrative Special Requirements Federal Funding Accountabilirv and 'fra.nsparenc,, Ad {FFATA) This statement of work is supported by federal funds that require compliance with the Federal Funding Accountability and Transparency Act (FFAT A or the Transparency Act). The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent. To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Universal Numbering System (DUNS®) number. Information about the LHJ and this statement of work will be made available on USASpending .gov by DOH as required by P.L. 109-282 . Program Manual, Handbook, Policy References Exhibit A, Statements of Work Revised as ofMarch 15, 2018 Page 5 of 18 Contract Number CLH18249-2