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Exhibit A <br />Statement of Work <br />Contract Term: 2018-2020 <br />AMENDMENT #4 <br />DOH Program Name or Title: Childhood l.ead Poisoning Prevention Program - <br />Effective January 1, 2018 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CLH18249 <br />SOW Type: Revision Revision # (for this SOW) 1 Funding Source Federal Compliance Type of Payment <br />D Federal <Select One> (check if applicable) [8J Reimbursement <br />Period of Performance: January 1, 2018 through June 30, 2019 [8J State D FFATA (Transparency Act) D Fixed Price <br />D Other D Research & Development <br />Statement of Work Purpose: The purpose ofthis 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: The purpose of this revision is to extend the period of performance from June 30, 2018 to June 30, 2019, add SFY2 funding and update the statement of work. <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 />SFYl Lead Environments of Children (proviso funds) NIA 334.04.93 25715110 01101118 I 06/30/18 2,000 0 2,000 <br />SFY2 Lead Environments of Children (proviso funds) NIA 334.04.93 25715120 01101118 I 06130119 0 1,500 1,500 <br />TOTALS 2,000 1,500 3,500 <br />Task *May Support PHAB Due Date/Time Payment <br />Number Task/ Activityillescription Standards/Measures Deliverables/Outcomes Frame Information and/or <br />Amount <br />1 Contact the provider to gather complete information on Submit the cempleted updated Ch il-d Mom/i/>,r, 9}' Jh c Reimbursement of up <br />~~ the 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 />b1 tp_s :/ I wwwn .cdc. 2ov/nnds s/condi1ions/lead- <br />elevated-blood-lev.el s'ease-definition/20 16/ <br />b) Call family and schedule a home visit. If <br />interpretation services are needed, contact DOH <br />at lead@doh.wa.gov. Note : Interpretation <br />services will not be reimbursed through the <br />ConCon process. <br />c) Visit the child's residence (or other sites where <br />the child spends significant amounts of time) at <br />least once <br />Exhibit A, Statements of Work <br />Revised as of July 16, 2018 <br />-IJ.lef:ld f(!(,w. fflH!5'1f;rJ,'l'fJ!l 3~f Child to $500 maximum per <br />Blood Lead Investigation Form via fel'-tJ1,,iflU. 9'0'•1q •· .. ·o •. •7 •• ~ home visit, p er child. <br />Washington Disease Reporting Submit as needed Up to two (2) home <br />System (WDRS) available through within 60 days visits per child not to <br />WA DOH indicating: after completion. exceed total funding <br />consideration . <br />a) Confirmed BLL <br />b) Date LHJ contacted the family Note: this excludes <br />c) Date the environmental indirect costs <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 />Page 3 of32 Contract Number CLH18249-4