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!

Referring Agency/Provider Contact Information

Question Title

* 1. Referring Agency/Provider Contact Information

Reporting Period (select the month the request was obtained)

Question Title

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

What Service Integration Team are you requesting funds from? 

Question Title

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

Dollar amount Service Integration paid for?

Question Title

* 4. Dollar amount Service Integration paid for?

What was purchased with the funding?

Question Title

* 5. What was purchased with the funding?

Category of funding spent

Question Title

* 6. Category of funding spent

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

Question Title

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

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

Question Title

* 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

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

Question Title

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

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

Question Title

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

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.

Question Title

* 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.

Does anyone in the home have a diagnosed disability?

Question Title

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

What services/resources is the individual/family receiving?

Question Title

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

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

Question Title

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

T