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<br /> <br /> <br /> <br />507 N. Nanum Street, Suite 102 Ellensburg, WA 98926 <br /> T: 509.962.7515 F: 509.962.7581 <br />www.co.kittitas.wa.us/health/ <br />HP Version: 1 Supersedes: 0 Date Adopted: 11/8/19 Modified/Created By: Chelsey Loeffers Approval By: T Lamb <br /> <br /> <br /> <br /> <br />Exhibit “E” <br />Quarterly Reporting Form <br />(CYSHCN Quarterly MCHBG Reporting Form) <br /> <br />Email report to: chelsey.loeffers@co.kittitas.wa.us or fax: 933-8246 by the 5th of the month <br />following the end of the quarter. <br /> <br /> <br />Facility reporting: CHCW-E Quarter period: <br /> <br />Name of reporter: Date CHIF entry completed: <br /> <br /> <br />What would you like to share with regional/statewide CYSHCN partners? Highlights, questions, <br />challenges, etc. <br /> <br />What’s new? <br /> <br /> <br /> <br /> <br />Factors to success or barriers: <br /> <br /> <br /> <br /> <br /> <br /> <br />