HomeMy WebLinkAboutExhibit E-CYSHCN Quarterly Reporting 2021-2022
507 N. Nanum Street, Suite 102 Ellensburg, WA 98926
T: 509.962.7515 F: 509.962.7581
www.co.kittitas.wa.us/health/
HP Version: 1 Supersedes: 0 Date Adopted: 11/8/19 Modified/Created By: Chelsey Loeffers Approval By: T Lamb
Exhibit “E”
Quarterly Reporting Form
(CYSHCN Quarterly MCHBG Reporting Form)
Email report to: chelsey.loeffers@co.kittitas.wa.us or fax: 933-8246 by the 5th of the month
following the end of the quarter.
Facility reporting: CHCW-E Quarter period:
Name of reporter: Date CHIF entry completed:
What would you like to share with regional/statewide CYSHCN partners? Highlights, questions,
challenges, etc.
What’s new?
Factors to success or barriers: