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S] <br />Kittitas Couniy <br />Public Health <br />S*p*rtrrsirl. <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 />Exhibit "F" <br />Annual Reporting Form <br />Unduplicated Count of lndividuals Served Under Title V by Class of lndividuals and percent of <br />Health Coverage <br />Email report to: chelsey.loeffers@co.kittitas.wa.us or fax: 933-g246 by November 3orh 2022 <br />Facilityreporting: CHCW-E Date: <br />Report the unduolicated number served for each population category served if a direct or <br />enablins service (the top two levels of the MCH Pyramid) was fully or partially supported withyour total MCH allocation. Estimate the percent with Title Xlx, Title XXl, other, or No/Unknown <br />Health Coverage. <br />Population <br />Category <br />A. <br />Total f <br />Served <br />with Title V <br />(partially <br />or fully <br />funded <br />with MCH <br />al <br />B. <br />Estimated <br />%with <br />Title xtx <br />coverage <br />c. <br />Estimated <br />% with <br />Title xxt <br />coverage <br />D. <br />Estimated % <br />with <br />Private/Other <br />coverage <br />E. <br />Estimated % <br />with No <br />health <br />coverage <br />F. <br />Estimated <br />% <br />Unknown <br />health <br />coverage <br />Total % <br />(should <br />be 100%) <br />Pregnant <br />Women <br />0.00% <br />lnfants<1 <br />yr. of age <br />0.00% <br />Children 1 <br />to22yr.0.00% <br />CYSHCN 0.00% <br />Others 0.00o/o <br />TOTAL 0 <br />HP Version: 1 Supersedes: 0 -pate Adopted:9/29/21 Modified/Created By: Chelsey Loeffers Approval By: T Lamb