SI Team Dollars Report Form

Santiam Service Integration Team Dollars-Reporting Form

Welcome to Santiam Service Integration Team Dollars Reporting Form. We thank you for taking the time to complete the funding reporting form. Please allow 5-10 minutes to complete the form. If you have questions about this form or need assistance filling it out please contact Melissa Baurer, Santiam SIT Coordinator, mbaurer@santiamhospital.org or 503-769-9319

Please provide as much detail as possible in your answers.

This report serves as a way to collect data on number of persons served with Service Integration Dollars. The information you provide allows the program to understand the community impact made by matching solutions to specific needs and collaboration with other partners.

Thank you! Your time is appreciated!

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* 1. Referring Agency/Provider Contact Information

Name (First &Last)

Agency/Company

Email Address

Phone Number

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* 2. Reporting Period (select the month the request was obtained)

Quarter 1: July- September

Quarter 2: October- December

Quarter 3: January-March

Quarter 4: April- June

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* 3. What Service Integration Team are you requesting funds from?

North Santiam SIT (Stayton, Sublimity, Lyons, Mehama)

Santiam Canyon SIT (Gates, Mill City, Idanha, Detroit)

Cascade SIT (Aumsville, Turner, Marion, and part of Salem)

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* 4. Dollar amount Service Integration paid for?

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* 5. What was purchased with the funding?

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* 6. Category of funding spent

Urgent Need (rent, utilities)

Basic Need (Food, Clothing, personal items)

Community Development (community events and activities)

Education (classes, tuition, fees, literacy programs)

Extra-Curricular (fees, materials, clothing needed for participation in extracurricular activities)

Health (prescriptions, co-pays, dental, transportation to medical appointments)

Supplies (goods or equipment necessary to carry out activities and programs)

Youth Development (Leadership/learning opportunities not part of regular school programs)

Transportation

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* 7. Describe the impact this funding had on the individual, family, group, or program served.

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* 8. Are there any In-Kind leveraged sources? (Please enter the In-Kind in numerical value) If there are no In-Kind leveraged sources continue to Q9

Source 1 (name of organization)

Donation Type 1 (crib,etc)

In-Kind Value 1 ( value of the donation- best estimate)

Source 2

Donation Type 2

In-Kind Value 2

Source 3

Donation Type 3

In-Kind Value 3

Source 4

Donation Type 4

In-Kind Value 4

Source 5

Donation Type 5

In-Kind Value 5

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* 9. Were there any cash leveraged sources? (please enter $ amount in numerical value) If not, continue to question 10

Source 1

$ Amount 1

Source 2

$ Amount 2

Source 3

$ Amount 3

Source 4

$ Amount 4

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* 10. Did you have Volunteers for the event? If yes, please complete this section.

Number of Volunteers

Value of volunteers in dollar amount (estimated)

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* 11. Indicate the number of people in the household that fall within each age group. If activity was for a large group, estimate the total number.

Adult Men (19+)

Adult Women (19+)

Youth 11-18 years old

Children 6-10 years old

Children who are 5 years of age

Children who are 4 years of age

Children who are 3 years of age

Children who are 2 years of age

Children who are 1 years of age

children who are 0- 11 months of age

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* 12. Does anyone in the home have a diagnosed disability?

Yes

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* 13. What services/resources is the individual/family receiving?

Oregon Health Plan (OHP)

Supplemental Nutritional Assistance Program (SNAP)

Women, Infants, and Children (WIC)

Temporary Assistance for Needy Families (TANF)

Child Welfare Involvement

Housing Assistance (public housing, long term housing programs)

None

Other (please specify)

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* 1. Referring Agency/Provider Contact Information

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* 2. Reporting Period (select the month the request was obtained)

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* 3. What Service Integration Team are you requesting funds from?

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* 4. Dollar amount Service Integration paid for?

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* 5. What was purchased with the funding?

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* 6. Category of funding spent

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* 7. Describe the impact this funding had on the individual, family, group, or program served.

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* 8. Are there any In-Kind leveraged sources? (Please enter the In-Kind in numerical value) If there are no In-Kind leveraged sources continue to Q9

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* 9. Were there any cash leveraged sources? (please enter $ amount in numerical value) If not, continue to question 10

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* 10. Did you have Volunteers for the event? If yes, please complete this section.

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* 11. Indicate the number of people in the household that fall within each age group. If activity was for a large group, estimate the total number.

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* 12. Does anyone in the home have a diagnosed disability?

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* 13. What services/resources is the individual/family receiving?

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* 14. Please share a success story that occurred because of the funding (if applicable)