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DOH Program Name or Title: COVID-19 Mass Vaccination -FEMA - <br />Effective January 1, 2022 <br />SOW Type: Orip-ina Revision # (for this SOW) <br />Period of Performance: January 1,2022 through April 1. 2022 <br />Exhibit A <br />Statement of Work <br />Contract Term: 2022-2024 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CLH31015 <br />Funding Source Federal Compliance Type of Payment <br />® Federal Contractor (check if applicable) ® Reimbursement <br />❑ State ® FFATA (Transparency Act) ❑ Fixed Price <br />❑ Other ❑ Research & Develo ment <br />Statement of Work Purpose: The purpose of this statement of work is to establish the task activities, fundingperiod, andbilling details for cost reimbursement ofFEMA-funded <br />mass vaccination clinics in Washington state. <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 Fund ing Period <br />Start Date End Date <br />Current <br />Allocation <br />Allocation <br />Change <br />g <br />None <br />Total <br />Allocation <br />*MASS VACCINATION FEMA 100% 934VO200 <br />97.036 <br />333.97.03 <br />01/01/22 04/01/22 <br />0 <br />0 <br />eligible costs. <br />0 <br />SUBRECIPIENT but are as a CONTRACTOR of DOH. <br />0 <br />0 <br />0 <br />MASS VACCINATION <br />DOH reimbursement provided for local mass vaccination <br />0 <br />0 <br />0 <br />(MI 934V0200) <br />0 <br />0 <br />0 <br />the Regional Incident Management Team (IMT) to <br />0 <br />0 <br />administer the vaccine efficiently, quickly, equitably, and <br />0 <br />Requirements below) <br />safely in all regions of Washington State. State Supported, <br />0 <br />0 <br />0 <br />TOTALS <br />0 <br />0 <br />0 <br />Task <br /># <br />Activity <br />Deliverables/Outcomes <br />Due Date/Time Frame <br />Payment Information <br />and/or Amount <br />1. <br />*NOTE: Task activities for Mass Vaccination Clinics in this <br />*Reimbursement of <br />statement of work are NOT CONSIDERED <br />eligible costs. <br />SUBRECIPIENT but are as a CONTRACTOR of DOH. <br />MASS VACCINATION <br />DOH reimbursement provided for local mass vaccination <br />FEMA 100% Funding <br />clinic (see definition below) planning, implementation and <br />(MI 934V0200) <br />operations in coordination between Unified Command and <br />the Regional Incident Management Team (IMT) to <br />(See Program Specific <br />administer the vaccine efficiently, quickly, equitably, and <br />Requirements below) <br />safely in all regions of Washington State. State Supported, <br />Regionally Coordinated, Locally Implemented. <br />Definition: Mass vaccination clinics defined as those outside of <br />the usualhealthcare delivery. method such as pop-up clinics, <br />mobile clinics, non -clinical facility (fairgrounds, arenas, etc.). <br />Exhibit A, Statement of Work Page 1 of 4 Contract NumberCLH31015 <br />