Survey

Value Capture Form

INSTRUCTIONS: Please complete this form during the year in order to capture value related data for later use in our year end Value Report.

Example -
1. Date: 07/04/2010
2. District: Briarcliff
3. Service: Video Conferencing
4. LHRIC Staff (involved): Sarah Martabano
5. District Staff (involved): Eric Knutsen
6. Your Name (person completing the form): John Hall
7. Describe how we helped the district beyond our SLA:
We provided VC unit to district for 6 months, at no charge, so they could test system and district's level of interest in this technology and our service. Estimated cost savings = $6,500.
8. How much time was spent on this effort? (staff time): 2 days

1. Date:

	MM		DD		YYYY
Enter today's date	Date: Enter today's date Month	/	Day	/	Year

2. District:

	District
Use drop down menu	District: Use drop down menu District

3. Service:

	Service
Use drop down menu	Service: Use drop down menu Service

4. LHRIC Staff (involved):

LHRIC Staff (involved):

5. District Staff (involved):

District Staff (involved):

6. Your Name (person completing this form):

Your Name (person completing this form):

7. Describe how we helped the district beyond our SLA. If applicable, include estimated financial savings.

Describe how we helped the district beyond our SLA. If applicable, include estimated financial savings.

8. How much time was spent on this effort?

How much time was spent on this effort? Total Hours