HomeMy WebLinkAboutDoc 698 - IGA Amend - OHA FundingDeschutes County Board of Commissioners
1300 NW Wall St., Suite 200, Bend, OR 97701-1960
(541) 388-6570 -Fax (541) 385-3202 -www.deschutes.org
AGENDA REQUEST & STAFF REPORT
For Board Business Meeting of December 19,2011
~: December 9, 2011
FROM: Nancy England, Contract Specialist, Deschutes County Health Services, 322-7516
TITLE OF AGENDA ITEM:
Consideration of Board Signature of Document #2011-698, Amendment # 3 to Intergovernmental
Financial Agreement Award #135558 between the Local Public Health Department and the Oregon
Health Authority for the financing of Local Public Health Services for fiscal year 2011-2013.
PUBLIC HEARING ON THIS DATE? No.
BACKGROUND AND POLICY IMPLICATIONS:
The Oregon Health Authority (OHA) was created by the 2009 Oregon legislature to bring most health
related programs in the state into a Single agency to maximize its purchasing power; the
Intergovernmental Agreement (#135558) outlines the services and finanCing for fiscal year 2011-2013.
There are separate grants associated with individual public health programs represented in the
Intergovernmental Agreement, ranging from disease prevention and maternal child health to school
based health centers, women, infants and children (WIC), bioterrorism preparedness and family
planning. Each grant has an associated set of Program Assurances which are the service and
quality performance expectations connected with the delivery of the various components of the
program itself.
Amendment #3 modifies the agreement as follows:
1-Program Element #01, Accreditation Readiness -Mini Grant -$50,000 allocation funds are
provided FY11-12 to be used to complete the activities required for National Accreditation.
The goal of public health accreditation is to improve and protect the health of the public by
advanCing the quality and performance of all health departments in the country, so that
residents can feel confident that their public health department is providing the highest
quality services possible.
2-Program Element #12, Public Health Emergency Preparedness -($13,010), amount
reflects a reduction of funds for Public Health Emergency Preparedness.
3-Program Element #44, School Based Health Centers -($16,030) The FY 2012 budget
assumes flat funding of the program; the reduction of funds reflects the change in funding
for each sight.
4-Program Element #40, "Women, Infants and Children" (WIC), $8,970 funds represent a
one-time year-end funding to agencies. The rate of the funding is $2 per assigned
caseload. WIC is a free nutrition education program which provides supplemental foods to
promote good health for pregnant, breastfeeding and postpartum women, infants and
children up to age five.
S-Program Element #47, Linking Actions for Unmet Needs in Child Health (LAUNCH) Project,
$709,347, funds represents the LAUNCH Grant. The purpose of the LAUNCH project is to
promote the wellness of young children, birth to eight (8) years of age. LAUNCH defines
wellness as optimal functioning across all developmental domains, including physical,
social, emotional, cognitive and behavioral health.
6-Program Element #48, "Teen Pregnancy Prevention", $1,236, funds are added for the
Personal Responsibility Education Program (PREP) for attendance at the PREP regional
training.
In addition to funding, Amendment #3 modifies the description for Program Element #47, "Family
Health Services -Project LAUNCH".
FISCAL IMPLICATIONS:
Maximum funding reimbursement for specific Program Elements for year 11-12 is $740,513.
I RECOMMENDATION & ACTION REQUESTED:
I Approval and signature of Document #2011-698, Amendment #3 to Intergovernmental Financial
Agreement Award #135558 between the Local Public Health Dept. and the Oregon Health Authority is
requested.
I ATTENDANCE: Kate Moore, Program Manager
DISTRIBUTION OF DOCUMENTS:
E-mail Signature Page (connie.thies@state.or.us) or fax 503-373-7889 the Signature Page;
f executed documents to Nancy England, Contract Specialist i
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DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form is required to be 8UbmitIed with ALL contracts and other agreements. regardless of whether the document is to be
on a Board agenda or can be signed by the County Administrator or Department Director. 11 the document is to be on a Board
agen(la. the Agenda Request Form is also required. If this form is not Included with the document. the document will be returned to
the Department. Please submit documents to the Board Secretary for tracking purposes. and not direcUy to Legal Counsel. the
County Administrator or the Commissioners. In addition to submitting this form with your documents. please submit this form
eledronicaUy to the Board Secretary.)
Pleese complete all sections above the OfficIal Review line.
Date: I November 30, 2011 I
Department: I Health Services, Public Health Division .1
Contractor/Supplier/Consultant Name: I Oregon Health Authority I
Contractor Contact: I Connie Thies, Office of Contracts & Procurements I
Contractor Phone #: I 503-373-7889 I
Type of Document: Amendment #3 to the Intergovernmental Agreement, #135558
Goods and/or Services: The Oregon Health Authority (OHA) was created by the 2009 Oregon
legislabJre to bring most health-related programs in the state into a single agency to maximize its
purchasing power; the Intergovernmental Agreement (#135558) outlines the services and financing
for fiscal year 2011-2013.
Background & History: Through the Intergovernmental Agreement, OHA administers Federal
public health grant funds, pools these funds with state funds and then allocates these to local
health departments. This is the primary means by which State and Federal public health funds
are delivered to the local public health authority for Deschutes County.
There are separate grants associated with individual public health programs represented in the
Intergovernmental Agreement, ranging from disease prevention and maternal child health to
school based health centers, women, infants and children (WIC), bioterrorism preparedness and
family planning. Each grant has an associated set of Program Assurances which are the
service and quality performance expectations connected with the delivery of the various
components of the program itself.
Amendment #3 modifies the agreement as follows:
1-Program Element #01, Accreditation Readiness -Mini Grant -$50,000 allocation funds
are provided FY11-12 to be used to complete the activities required for National
Accreditation. The goal of public health accreditation is to improve and protect the
health of the public by advancing the quality and performance of all health departments
in the country, so that residents can feel confident that their public health department is
providing the highest-quality services possible.
2-Program Element #12, Public Health Emergency Preparedness -($13,010). amount
reflects a reduction of funds for Public Health Emergency Preparedness.
3-Program Element #44, School Based Health Centers -($16,030) The FY 2012 budget
assumes flat funding of the program; the reduction of funds reflects the change in
funding for each sight.
4-Program Element #40, "Women, Infants and Children" (WIC), $8,970 funds represent a
one-time year-end funding to agencies. The rate of the funding is $2 per assigned
caseload. WIC is a free nutrition education program which provides supplemental foods
to promote good health for pregnant, breastfeeding and postpartum women, infants and
children up to age five.
S-Program Element #47, Linking Actions for Unmet Needs in Child Health (LAUNCH)
Project, $709,347, funds represents the LAUNCH Grant The purpose of the LAUNCH
project is to promote the wellness of young children, birth to eight (8) years of age.
LAUNCH defines \Y8l1ness as optimal functioning across all developmental domains,
including phYSical, social, emotional, cognitive and behavioral health.
6-Program Element #48, "Teen Pregnancy Prevention", $1,236, funds are added for the
Personal Responsibility Education Program (PREP) for attendance at the PREP regional
training.
In addition to funding, Amendment #3 modifies the description for Program Element #47,
"Family Health Services -Project LAUNCH",
Agreement Starting Date: 1 July 1, 2011 I Ending Date: I June 30, 2013
Annual Value or Total Payment: I $740,513 FY11-12.
[81 Insurance Certificate Received (check box)
Insurance Expiration Date: I County is Contractor
Check all that apply:
D RFP, Solicitation or Bid Process
D Informal quotes «$150K)
[81 Exempt from RFP, Solicitation or Bid Process (specify -see DCC §2.37)
Funding Source: (Induded in current budget? [81 Yes D No
If No, has budget amendment been submitted? DYes D No
Is this a Grant Agreement providing revenue to the County? DYes [81 No
Special conditions attached to this grant:
Deadlines for reporting to the grantor: .....1 _---'
If a new FTE will be hired with grant funds, confirm that Personnel has been notified that
it is a grant-funded position so that this will be noted in the offer letter: DYes D No
Contact information for the person responsible for grant compliance: Name:
Phone#:D
11/30/2011
Departmental Contact and Title: I Nancy England, Contract Specialist
Phone #: I 541-322-7516 I
Department Director Approval: ~~, ~I).'/Ll\t
Signature Date
Distribution of Document: e-mail SignaturePage(connie.thies@state.oLus) or fax
503-373-7889 the entire Signature Page; executed documents to Nancy England,
Contract Specialist
Official Review:
County Signature Required (check. one): III eocc 0 Department Director (if <$25K)
o Administrator (if >~~5K but <~1~~r$150K, eocc Order No. )
Legal Review J~k. (~ Date /2 -\'-It
Document Number :::;20:.,1=-:1:...;-6:.:98=-_______
IIWD 7hVt~ ('M
LEGAL COUNSEL
In compliance with the Americans with Disabilities Act, this document is available in
alternate formats such as Braille, large print, audiotape, oral presentation and electronic
format. To request an alternate format, please send an e-mail to dhsalt@State.or.us or
contact the Office of Document Management at 503-378-3486, and TTY at 503-378
3523
Agreement #135558
THIRD AMENDMENT TO OREGON HEALTH AUTHORITY
2011-2013 INTERGOVERNMENTAL AGREEMENT FOR THE
FINANCING OF PUBLIC HEALTH SERVICES
This Third Amendment to Oregon Health Authority 2011-2013 Intergovernmental Agreement J for the Financing of Public Health Services, effective July I, 2011 (as amended the "Agreement"), is I between the State of Oregon acting by and through its Oregon Health Authority ("OHA") and Deschutes
County, acting by and through its Deschutes County Health Services ("LPHA"), the entity designated,
pursuant to ORS 431.375(2), as the Local Public Health Authority for Deschutes County.
RECITALS
WHEREAS, OHA and LPHA wish to modify the set of Program Element Descriptions set
forth in Exhibit B of the Agreement and ...
WHEREAS, OHA and LPHA wish to modify the Financial Assistance Award set forth in
Exhibit C of the Agreement.
NOW, THEREFORE, in consideration of the premises, covenants and agreements contained
herein and other good and valuable consideration, the receipt and sufficiency of which is hereby
acknowledged, the parties hereto agree as follows:
AGREEMENT
1. Exhibit B. "Program Element Descriptions" is amended as follows: Program Element #47:
Family Health Services ("FHS") -Project LAUNCH (Deschutes Co. only) is added as set forth
in Exhibit I attached hereto and incorporated herein by this reference. Related program
funding is awarded as set forth in Exhibit 2 to this Amendment.
2. Section I of Exhibit C entitled "Financial Assistance Award" of the Agreement is hereby
superseded and replaced in its entirety by Exhibit 2. attached hereto and incorporated herein by
this reference. Exhibit 2. must be read in conjunction with Section 4. of Exhibit C, entitled
"Explanation of Financial Assistance Award" of the Agreement.
3. LPHA represents and warrants to OHA that the representations and warranties of LPHA set
forth in Section 2 of Exhibit E of the Agreement are true and correct on the date hereof with the
same effect as if made on the date hereof.
4. Capitalized words and phrases used but not defined herein shall have the meanings ascribed
thereto in the Agreement.
2011-2013 Intergovernmental Agreement for the Financing of Public Health Services Page 1 of 8 pages
135558-3 pgm.doc Deschutes County
DC -2011-698
5. Except as amended hereby, all tenns and conditions of the Agreement remain in full force and
effect.
6. This Amendment may be executed in any number of counterparts, all of which when taken
together shall constitute one agreement binding on all parties, notwithstanding that all parties
are not signatories to the same counterpart. Each copy of this Amendment so executed shall
constitute an original.
7. This Amendment becomes effective on the date of the last signature below.
IN WITNESS WHEREOF, the parties hereto have executed this Amendment as of the dates set
forth below their respective signatures.
APPROVED:
STATE OF OREGON ACTING BY AND THROUGH ITS OREGON HEALTH AUTHORITY (OHA)
By:
Name: Jean O'Connor, JD, DrPH
Title: Deputy Public Health Director
Date:
DESCHUTES COUNTY ACTING BY AND THROUGH ITS DESCHUTES COUNTY HEALTH SERVICES
(LPHA)
By:
Name:
Title:
Date:
OHA OF JUSTICE -ApPROVED FOR LEGAL SUFFICIENCY
Approved by D. Kevin Carlson, Senior Assistant Attorney General on October 14,2011. Copy
ofapproval on file at OC&P .
OFFICE OF CONTRACTS & PROCUREMENT (OC&P)
By:
Name: Phillip G. McCoy, OPBC
Title: Contract Specialist
Date:
2011-2013 Intergovernmental Agreement for the Financing of Public Health Services Page 2 of 8 pages
135558·3 pgm.doc • Deschutes County
EXHIBIT 1
PROGRAM ELEMENT DESCRIPTIONS
Program Element #47: Family Health Services ("FHS") -Project LAUNCH
(Deschutes Co. only)
1. General Description and Purpose.
a. The Substance Abuse and Mental Health Services Administration, SAMHSA has awarded
funds to the State of Oregon to initialize and support specific ongoing activities related to
"Linking Actions for Unmet Needs in Children's Health" (Project LAUNCH). The purpose
of Project LAUNCH is to promote the wellness of young children, birth to eight years of
age. Project LAUNCH defines wellness as optimal functioning across all developmental
domains, including physical, social, emotional, cognitive and behavioral health. Project
LAUNCH is a five year grant, from 2009-2014, with a demonstration project component in
Deschutes County.
b. The purpose of Oregon LAUNCH is to develop a state and local coordinated child-serving
system that integrates behavioral and physical health services. Oregon LAUNCH will
provide an integrated and holistic system of wellness, prevention and treatment services to
assist 1,500 children, birth to eight-years of age, and their families in Deschutes County,
Oregon over a five-year period.
c. The funds provided under this Financial Assistance Agreement for this Program Element
shall only be used, in accordance with and subject to the requirements and limitations set
forth below, as supplemental funds to support Oregon LAUNCH.
2. Definitions Specific to Oregon LAUNCH.
a. Early Childhood Matters -Oregon's framework for a statewide birth-through-five Early
Childhood system.
b. The Early Childhood Council (ECC) -This council consist of three subcommittees:
• Health Matters
• Early Learning Matters
• Family Matters
3. Local Project LAUNCH Resources, Organizations, and Related Programs:
a. Child Care Resource and Referral is the resource and referral that provides services and
mental health consultation to childcare providers.
b. Deschutes County Commission on Children and Families (DCCF) is a governmental
agency that promotes child abuse prevention and early intervention through early childhood
care, education and community partnerships.
2011-2013 Intergovernmental Agreement for the Financing of Public Health Services Page 3 of 8 pages
135558-3 pgm.doc -Deschutes County
c. Deschutes County Health System -School-Based Health Centers (DCHS-SBHC) are
primary care health clinics located in the elementary schools in Deschutes County.
d. Family Access Network (FAN) is a local non-profit organization that provides family
advocacy services in every public school to assist children and families in accessing
services to meet basic needs .
e. .Family Access Network Coalition (18 organizations) is a school based organization that
advocates for children and families.
f. Family Resource Center (FRC) is the primary local provider for parenting education.
FRC currently uses:
o Incredible Years (IY)
o Parenting Wisely (PW)
g. Healthy Beginnings is a prevention-focused program to ensure that children meet age
appropriate developmental standards upon entering kindergarten and increase parents' skills
by bringing accessible, educational, preventive screenings to children ages birth to 5 and
their parents.
h. Healthy Families of the High Desert is a child abuse prevention program that provides
parent groups and home visitation services to first time parents.
i. KIDS Center is a local organization that offers advocacy, child abuse prevention programs,
medical assessments, victim counseling, family therapy, and parent training services.
j. Latino Community Association is a local organization that serve as the resource for the
local Hispanic community.
k. Local Interagency Coordinating Council is a group of providers and families who
coordinate services for children with disabilities.
I. Mountain Star Family Relief Nursery is an emergency childcare and support system for
families that are facing domestic violence, child abuse, and neglect.
m. Neighbor Impact is the local organization that provides Head Start programs.
n. Parent Child Interaction Therapy is an intervention developed to reduce child behavioral
problems and risks for child abuse.
o. Promoting First Relationships is an intervention model that to promote trusting and
secure caregiver-child relationships and the child's healthy social emotional development.
4. Procedural and Operational Requirements. The funds provided under this Cooperative
Agreement between SAMHSA, the State of Oregon Department of Human Services, and
Deschutes County shall only be used to support activities related to planning, administration,
operation, and delivery of services as outlined by the SAMHSA Project LAUNCH grant
guidelines.
2011·2013 Intergovernmental Agreement for the Financing of Public Health Services Page 4 of 8 pages
135558·3 pgm.doc . Deschutes County
a. SAMHSA Project LAUNCH -Specific Local Requirements and Timelines
1.) Create and fill the local-level position of Child Wellness Coordinator by l<ln11<"'"
2010.
2.) Convene Deschutes County Council on Young Child Wellness on a recurring basis.
3.) Develop a local level strategic plan for the LAUNCH initiative by May 17th, 2010.
4.) Implement local level changes in child wellness policy, service systems, evaluation,
as indicated by the LAUNCH strategic plan throughout the 5 year grant cycle, 2009
2014.
5.) Participate in the Evaluation Task Force and contribute data to the Evaluation Plan on
a recurring basis.
6.) Train providers on Evidence Based Program Interventions identified in the Grant:
Promoting First Relationships, Parents as Teachers, Parent Child Interaction Therapy
and Incredible Years throughout the 5 year grant cycle, 2009-2014.
7.) Increase early identification of development and mental health issues through
comprehensive developmental assessments and referral. The School Based Health
Centers will begin using these developmental assessments by March 20 IO.
8.) Integrate Parent Child Interaction Therapy into primary care in school-based health
clinics and FQHC settings throughout the 5 year grant cycle, 2009-2014.
9.) Create Healthy Child Family Support Teams (HCFST) at the School Based Health
Centers (SBHC). These HCFSTs will consist of a nurse practitioner, a mental health
consultant and a family access network advocate, who will provide coordinated
services and healthcare in a "Medical Home" model. The HCFST will provide care
throughout the 5 year grant cycle, 2009-2014.
10.) Implement "Promoting First Relationships" in the Deschutes County public health
nurse home visiting program by December, 2010.
11.) Expand "Parents as Teachers" into the community home visitation programs offered
by Healthy Families of the High Desert throughout the 5 year grant cycle, 2009-2014.
12.) Provide parent skills training using: Incredible Years" and "Parenting Wisely"
curricula by ==....=~.
13.) Work with DCHS Public Information Coordinator to create and implement a Young 1 Child Wellness campaign by December, 2011.
I
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2011·2013 Intergovernmental Agreement for the Financing of Public Health Services Page 5 of 8 pages
135558·3 pgm.doc • Deschutes County
1
b. Reporting Obligations and Periodic Reporting Requirements. In addition to the
reporting obligations set forth in section 8 of Exhibit E, of this Agreement, LPHA, will
submit a quarterly invoice to the DHS Contract Administrator describing work performed,
time lines and budget updates on a quarterly basis during the current Agreement period.
2011-2013 Intergovernmental Agreement for the Financing of Public Health Services Page 6 of 8 pages
135558-3 pgm.doc • Deschutes County
EXHIBIT 2
FINANCIAL ASSISTANCE AWARD
I
1) Grantee
State of Oregon
Oregon Health Authority
Public Health Division
2) Issue Date
Name: Deschutes County Health Dept. September 22, 201'1
Street: 2577 N. E. Courtney 3} Award Period
Page 1 of];
This Action
AMENDMENT
FY2012
City: Bend From July!, 2011 Through June 3D, 2012
State: OR lip Code: 97701
4) OHS Public Health Funds Approved
Previous Increase! Grant
Program Award (Decrease) Award
PE 01 State Support for Public Health 177,089 ° 177,089
PE 01 Accreditation Readiness Mini Grant 0 50,000 50,000
(i)
PE 03 TB Case Management 3,447 0 3,447
PE 07 HIV Prevention Services 37,696 0 37,696
HIV Prevention Block Grant Services
Ryan White Title II HIV I AIDS Services
PE 08 Ryan White--Case Management 72,392 0 72,392 i
PE 08 Ryan White-Support Services 25.448 ° 25,448
PE 12 Pub. Health Emergency Prep::uednessl(July-Aug. 9) '14.755 0 14,755
( b )
PE12 Pub. Health Emergency PreparednessJ{Aug 10-June30} 108,640 (13,010) 95,630
PE 13 Tobacco Prevention & Education 112,727 0 "12,727
PE 15 Healthy Communities Phase 2 65,000 0 65,000
PE 40 Women, Infants and Children 659,469 8,970 668,439
FAMILY HEALTH SERVICES cdghlm
5) FOOTNOTES:
a) Funds will not be shifted between categories or fund types_ The same program may be funded
by more than one fund type, however, federal funds may not be used as match for other federal
funds ( such as Medicaid ).
b) July 1 -Augllst 9th awards must be spent by 8f9l11 and a report submitted for that period
c) July-September grant is $175,423 and includes $35,085 of minimum Nutritional Education and
$7,586 for Breastfeeding Promotion.
d) October through June grant is $493,917 and includes $98,603 of minimum Nutritional Education
and for Breastfeedil1g Promotion_
e) The Fiscal Year 2012 budget assumes flat funding of the program. The final 2012 School Based
Health Center budget will be determined based upon the number of certified SHBC's on
July I , 2011 and the legislatively adopted budget
f) S 193233 is the total Family Planning grant; $132,051 is Title X and $6'1.182 is Title V
6) Capital Outlay Requested in This Action:
Prior approval is required for Capital Outlay. Capital Outlay is defined as an expenditure for equip
ment with a purchase price in excess of $5,000 and a life expectancy greater than one year.
PROG,
PROGRAM ITEM DESCRIPTION COST APPROV
I
Ij
2011·2013 Intergovernmental Agreement for the Financing of Public Health Services Page 7 of 8 pages
135558-3 pgm.doc • Deschutes County
I
State of Oregon Page 2 of 2
Oregon Health Authority
Public Health Division
1) Grantee 2) Issue Date This Action
Name: Deschutes County Health Dept. September 22, 2011 AMENDMENT
FY2012
Street: 2577 N. E. Courtney J) Award Period
City: Bend From July 1, 2011 Through June 30, 2012
State: OR Zip Code: 97701
4} DHS Public Health Funds Approved
Previous Increasel Grant
Program Award (Decrease) Award
PE 41 Family Planning Agency Grant '193,233 0 193.233
FAMILY HEALTH SERVICES (f)
PE 42 MCH/Chikl & Adolescent Health General Fund 11,077 a 11,077
FAMILY HEALTH SERVICES I (3)
PE 42 MCH-TitleV Child & Adolescent Health 17,261 0 17,261
FAMILY HEALTH SERVICES ( a )
PE 42 MCH-TitleV Flexible Funds 40.276 0 40,276
FAMILY HEALTH SERVICES ( a )
PE 42 MCHIPerinatal Health Genera! Fund 5,904 0 5,904
FAMILY HEALTH SERVICES ( a )
PE 42 Babies First 18,692 0 18,692
FAMILY HEALTH SERVICES
PE 42 Oregon MothersCare 15,995 0 15,995
FAMILY HEALTH SERVICES
PE 43 Immunization Special Payments 42,332 0 42,332
FAMtLYHEALTH SERVICES
PE 44 School Based Health Centers 221,030 (16,030) 205,000
FAMILY HEALTH SERVICES (e,i)
PE 47 Linking Actions for Unmet Needs in Child Health Project 0 709.347 709,347
FAMILY HEALTH SERVICES
PE 48 Teen Pregnency Prevention -P. R E. P. 107,040 '1,236 108,276
FAMilY HEALTH SERVICES ( k )
TOTAL 1,949,503 740,513 2,690,016
5) FOOTNOTES:
g) $12.760 represents the adjustment to the indial SFY2012 grant contract so that the total base
rate per participant increases by three percent compared to SFY2011.
h) $2,114 represents targeted nutrition education support for increasing consumption of fresh
fruits and vegetables.
iJ -$3,206 was the change in funding for each site.
DS50,000 funding to be used to complete the activities described in counties approved mini
grant for Accreditation Readiness. Expenditures must be tracked and reported separately.
k) $1 is for attendance at the Persona! Responsibility Education Program regional training.
I) $8,770 represents one-time year-end funding to local agencies to be spent by 9130/2011
The rate of the funding is $2.00 I assigned caseload.
m} 5200 represents travel expense reimbursemenl to local agencies for Farmers Market local
agency monitoring.
6) Capita.1 Outlay Requested in This Action:
Prior approval is required for Capital Outlay. Capital Outlay is defined as an expenditure for equip
ment with a purchase price in excess of $5,000 and a life expectancy greater than one year.
PROGRAM ITEM DESCRIPTION
I
I
PROG.
COST APPROV
2011-2013 Intergovernmental Agreement for the Financing of Public Health Services Page 8 of 8 pages
135558-3 pgm.doc • Deschutes County
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1
DESCHUTES COUNTY BEHAVIORAL HEALTH
REQUEST FOR TRAINING
FROM: DATE:
Title of Training:
Location:
Dates of From To
Hours of + Travel Hours: Total Training Time:
Description of Plans for Travel, Lodging and Time Out of Office:
~
RESPONSIBILITY OF:
(Place check in appropriate
box)
Associated Cost
COUNTY EMPLOYEE N/A
Fees
Travel
Lodging
Meals
Time Away from Work
Other
TOTAL
How will the skills be used to improve program effectiveness, public service
and evidence-based practice? As a result of the training, I will be able to:
----------------~~....... ------------
signature Date
TO BE COMPLETED BY SUPERVISOR:
# of training hours approved this fiscal year:
Total Cost paid county this fiscal year:
Supervisor signature Date
Manager signature Date
Director signature (for out of state or over $500) Date
j
8/4/10
http://insidedc/hea1th/Forms/Request for Training.doc
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