Administrative Review Tool and Program Summary Form



Pre-Review Information Sheet

This questionnaire is administered every three years several months prior to the LPHA’s triennial review. Information submitted will be shared with reviewers to help prepare for the overall review. Additionally, this information will help inform the Oregon Health Authority Public Health Division’s understanding of the structure of Oregon’s evolving public health system.

|Date:       |

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|Name of Person Completing this Information Sheet:       |

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|Title:       |

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|Name of Local Public Health Authority (LPHA), as defined under ORS 431.003(7): |

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|Type of LPHA: |

| | |A county government |

| | |A health district formed under ORS 431.443 (Formation of health districts) |

| | |An intergovernmental entity that provides public health services pursuant to an agreement entered into under ORS 190.010 |

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|Structure of the LPHA: |

| | |LPHA operates all or most public health services within the LPHA governmental structure |

| | |100% of non-governance public health services are contracted to other entities |

| | |LPHA contracts for most or all clinical public health services and operates some or all non-clinical core public health services within the LPHA |

| | |governmental structure |

| | |Cross Jurisdictional Health District |

| | |Other (describe): |

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|If applicable, list public health services or activities that the LPHA subcontracts to another entity, if those services are 1) pursuant to a contract or agreement |

|between the LPHA and OHA and 2) have a direct impact on consumers of the public health services. Do not list contracts for specific goods or professional services, or |

|for services that do not directly impact consumers. Refer to the guidance and examples in the memo to LPHAs “OAR 333-014-0570(2) Notification of intent to contract for|

|Public Health Services”; that guidance also applies to what should be listed in this Pre-Review Information Sheet. |

|Please include the amount contracted, the contract period (if not ongoing), and a description of which part of the work is contracted to another entity. |

|Enter N/A if the LPHA does not subcontract public health programs or services to other entities. |

| |Program Element Name or Environmental Health |

| |Funding amount subcontracted, and contract period (if not ongoing through entire triennial review period) |

| |Name of subcontractor |

| |Description of subcontracted services |

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|Describe any cross-jurisdictional sharing agreements, if not listed above: |

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|Does the LPHA conduct a new Community Health Assessment (CHA) and develop a new community health improvement plan (CHIP) at least every five years? |

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| | The CHA and CHIP is (check all that apply): |

| | |Specific to the LPHA |

| | |In coordination with a non-profit hospital |

| | |In coordination with a CCO |

| | |Other |

| |Include links to final CHA and CHIP reports, if there are more recent versions than the ones posted on the OHA website at |

| |. |

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|If the CHA and CHIP is in coordination with other partners (e.g. Coordinated Care Organizations or Early Learning Hubs), please describe the LPHA’s role and |

|responsibilities in its development. |

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|Describe any public health programs provided outside of the IGA for the Financing of Public Health Services and the Environmental Health IGA according to the |

|community’s health needs. |

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