1.Name of Agency

2.Contact at Agency, name and email address

3.Did you use any CalHope funds to purchase electronic devices?

Yes (if answered "yes" please continue survey)

No (if answered "No" please submit survey)

4.Device(s) purchased and serial number (or IMEI number)

5.Date purchased

6.Are you currently receiving other grants from DHCS that you will use these devices for? If yes, please list.

7.Are you currently receiving grants from other state depts, besides DHCS that you will use these devices for? If yes, please list.

8.If you responded yes to Qs 5 or 6, please confirm that you will not be purchasing duplicate equipment across your state contracts.

Yes

No

9.If you have no other state grants for which you would use the devices, you must return the devices to DHCS. If this is the case, select yes.

Yes, we will have to return the devices to DHCS

No, no devices need to be returned to DHCS