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I <br />l(ittitas County <br />Public Health <br />D€psrtmsnt <br />507 N. Nanum Street, Suite 102 Ellensburg,WA9g926 <br />T: 509.962.7515 F : 509.962.7581 <br />www.co.kittitas.wa. us/health/ <br />Facilityreporting: CHCW-E <br />Name of reporter: <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: g33-g2 46 bythe 5th of the monthfollowing the end of the quarter. <br />Quarter period: <br />Date CHIF entry completed: <br />What would you like to share <br />challenges, etc. <br />with regional/statewide CySH CN partners? Highlights, questions, <br />What's new? <br />Factors to success or barriers <br />HP Version: I Supersedes: 0 I 9 :\pproval By: T Lamb