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* <br />Kittitas Ccu nty <br />Pulclic Health <br />Department <br />507 N. Nanum Street, Suite 102 Ellensburg, WA 98926 <br />T: 509.962.7 515 F: 509.962.7 581 <br />www.co.kittitas. wa.us/health/ <br />Exhibit "E" <br />Quarterly Reporting Form <br />(CYSHCN Quarterly MCHBG Reporting Form) <br />Email report to: chelsey.loeffers@co.kittitas.wa.us or fax: 933-82 46 by the 5th of the month <br />following the end of the quarter. <br />Facilityreporting: CHCW-E Quarter period: <br />Name of reporter:Date CHIF entry completed <br />What would you like to share with regional/statewide CYSHCN partners? Highlights, questions, <br />challenges, etc. <br />What's new? <br />Factors to success or barriers: <br />FOR OFFICIAL USE ONLY: <br />Accepted By: <br />Permit #: <br />Date Processed: <br />HP Version: 1 Supersedes: 0 Date Adopted: ll/8119 Modified/Created By: Chelsey Loeffers Approval By: T Lamb