SERVICE DELIVERY SITE - Department of Public Health

SERVICE DELIVERY SITE & CONTRACT GOALS/OBJECTIVES WORKSHEET (Rev 10/2015)
Agency: _____________________________________ Service Category: ___________________________________
Contract Number:____________________________ Term: _____________________________________________
The following information will be used to negotiate your contract goals, objectives and budgets for the upcoming contract term.
Goals and Objectives |
Service Delivery Site Address |
(enter goal) |
(enter goal) |
(enter goal) |
(enter goal) |
Allocation % Designation
|
SPA |
Supervisor’s District | |Service
Unit | |No. of Clients |No. of Hours |No. of Clients |No. of Hours |No. of Clients |No. of Hours |No. of Clients |No. of Hours | | | | |
Site # 1 | | | | | | | | | | | | | |
Site # 2 | | | | | | | | | | | | | |
Site # 3 | | | | | | | | | | | | | |
Site # 4 | | | | | | | | | | | | | |
Site # 5 | | | | | | | | | | | | | |
TOTAL | | | | | | | | | | | | | |
I acknowledge that the Service Delivery Site and Goals and Objectives Worksheet has been accurately completed to the best of my knowledge and may be used to prepare the contract for the above noted contract term.
________________ __________________________________ __________________
Agency Head Name Agency Head or Designee Signature Date
-----------------------
FOR DHSP USE ONLY: Approved _______ Not approved _______
__________________________________ ____________________
Program Manager Name Program Manager Signature Date
__________________________________ ____________________
Supervisor Name Supervisor Signature Date
................
................
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