SERVICE DELIVERY SITE

SERVICE DELIVERY SITE AND CONTRACT GOALS AND OBJECTIVES WORKSHEET
Agency: ________________________________________________ Service Category: ______________________________________
Contract Number:___________________ Executive Director: ____________________________ 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 | | | | | | | | | | | | | |
Site # 6 | | | | | | | | | | | | | |
Site # 7 | | | | | | | | | | | | | |
Site # 8 | | | | | | | | | | | | | |
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
____ __________________________________ ____________________
Program Manager Name Chief/Supervisor Signature Date
................
................
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