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!

* 1. Referring Agency/Provider Contact Information

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

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

* 4. Dollar amount Service Integration paid for?

* 5. What was purchased with the funding?

* 6. Category of funding spent

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

* 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

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

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

* 11. Indicate the number of people served because of the funding received. If activity was for a large group, estimate the total number.

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

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

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