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AMENDMENT #19 Exhibit A, Statements of Work Revised as of January 15, 2021 Page 14 of 30 Contract Number CLH18249-19 Special References (RCWs, WACs, etc.) County Health Emergency Documentation if applicable Monitoring Visits (frequency, type): Occasional visits from DOH or IMT/IMO personnel for the purpose of monitoring and surveillance of mass vaccination activities may be expected. Definitions Mass vaccination clinic are those outside of the usual healthcare delivery methods such as pop -up clinics, mobile clinics, non-clinical facility clinics (i.e., fairgrounds, arenas, etc.). Special Billing Requirements: Monthly invoices must be submitted timely to the regional IMT/Organization for review/approval prior to submission to DOH for reimbursement. Contract (MI) Code: 934V0200 General Mass Vaccination BARS Revenue Code: 333.97.03 Mass Vaccination Reimbursement Special Instructions: The LHJ is considered a CONTRACTOR of DOH not a subrecipient for this portion of the statement of work. An allocation of fund s is not provided as these FEMA funds are only available as reimbursement of costs associated with implementation of the mass vaccination plan. Detailed documentation must be maintained as directed by the regional IMT/Organization and DOH to substantiate costs associat ed with these activities for submission to FEMA upon request by DOH. Eligible costs from the timeframe of January 21, 2021 through April 20, 2021 include facility rentals, medical and support staff for planning, managem ent, support, and operations; as well as wrap-around services for staff (i.e., meals, travel, lodging). Regular and overtime pay as sociated with this project is allowable for all staff working under this project and must be billed as a direct charge; timesheets are required documentation and must be available upon request by DOH. Indirect rates are not applicable to these funds. Eligible equipment includes facility infection control measures, personal protective equipment (PPE), storage equipment, coolers, freezers, temperature monitoring devices, portable vaccine units for transportation, supplies such as emergency medical supplies (for emergency medical care needs that may arise in the administration of the vaccine), containers for medical waste, as well as proper storage as needed for canisters of liquid nitrogen or dry ice. Eligible equip ment purchase costs should not exceed $5,000 per piece. Equipment over $5,000 a piece must be preapproved by the IMT and should be leased rather than purchased. Any diversion from t he list of pre-approved expenses will require a narrative on the purchase rationale and will be subject to IMT approval prior to reimbursement. Timesheets are required documentation for all activities related to this project. Staff time-in / time-out must be recorded, as well as a brief description of their activities. A general description of activities is acceptable f or those working at the vaccine site; more detailed/specific description is required for those not working at the vaccine site. DOH Program Contact Kasey Walker Alyssa Lavin, LHJ Contract Manager DOH, PHOCIS 1610 NE 150th St, Shoreline, WA 98155 kasey.walker@doh.wa.gov alyssa.lavin@doh.wa.gov / 360-236-3273 DOH BITV-COVID ED LHJ Allocation-CARES Fiscal Contact (Tasks 1 and 2) Sheri Spezze DOH, Office of Program Financial Management PO Box 47840, Olympia, WA 98504-7841 Ph: 360-236-4447 / Fax: 360-664-2216 / sheri.spezze@doh.wa.gov