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Exhibit A <br />Statement of Work <br />Contract Term: 2022-2024 <br />DOH Program Name or Title: LSPAN-Local Strategies for Physical Activity & <br />Nutrition - Effective January 1, 2022 <br />SOW Type: Ori�alal Revision # (for this SOW) <br />Period of Performance: January 1 202 through September29, 2022 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CLH31015 <br />Funding Source Federal Compliance Type of Payment <br />® Federal Subrecipient (check if applicable) ® Reimbursement <br />❑ State 0 FFATA (Transparency Act) ❑ Fixed Price <br />❑ Other ❑ Research & Development <br />Statement of Work Purpose: The purpose of this statement of work is to establish funding for Local Strategies for Physical Activity and Nutrition (LSPAN), a project of the <br />State Physical Activity and Nutrition Program (SPAN). <br />Revision Purpose: N/A <br />Master <br />Index <br />DOH Chart of Accounts Master Index Title Code <br />Assistance <br />Listing <br />Number <br />BARS <br />Revenue <br />Code <br />LHJ Funding Period <br />Current <br />Start Date End Date Allocation <br />Allocation <br />Chan e <br />g <br />Increase (+) <br />Total <br />Allocation <br />FFY21 PHYS ACTVTY & NUTRITION PROG 77440241 <br />93.439 <br />333.93.43 <br />01/01/22 09/29/22 0 <br />34,000 <br />34,000 <br />staff will participate in <br />actualcosts, not to <br />0 <br />0 <br />0 <br />exceed total contract <br />0 <br />0 <br />0 <br />funding. See Program <br />mutually agreed upon between DOH <br />0 <br />0 <br />0 <br />and Kittitas County Public Health <br />0 <br />0 <br />0 <br />Department (KCPHD). <br />0 <br />0 <br />0 <br />TOTALS <br />January 1, 2022 — September 29, 2022 <br />Reimbursement for <br />0 <br />1 34,000 <br />1 34,000 <br />Task <br /># <br />Activity <br />Deliverables/Outcomes <br />Due Date/Time Frame <br />Payment Information <br />and/or Amount <br />1 a <br />PROGRAM ADMINISTRATION: <br />Designated KCPHD <br />January 1, 2022 — September 29, 2022 <br />Reimbursement for <br />Participate in calls, ata minimum of <br />staff will participate in <br />actualcosts, not to <br />once every month, with DOH contract <br />contract management <br />exceed total contract <br />manager. Dates and time for calls are <br />calls. <br />funding. See Program <br />mutually agreed upon between DOH <br />Specific Requirements <br />and Kittitas County Public Health <br />Department (KCPHD). <br />lb <br />PROGRAM ADMINISTRATION: <br />Designated KCPHD <br />January 1, 2022 — September 29, 2022 <br />Reimbursement for <br />Participate in DOH -sponsored LSPAN <br />staff will participate in <br />actual costs, not to <br />related quarterly conference calls <br />calls, webinars, and <br />exceed totalcontract <br />and/orwebinars, including up to one <br />meetings. <br />funding. See Program <br />1 in-person meeting. <br />Specific Requirements <br />Exhibit A, Statement of Work Page 1 of 3 Contract NumberCLH31015 <br />Template Created September 2021 <br />