Alameda County Measure A Oversight Committee

By Darlene Lee,2014-08-08 21:24
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Alameda County Measure A Oversight Committee

    Alameda County Measure A Oversight Committee

    FY 05/06 Review of Funding Allocations Reporting Requirements

(Form updated on May 29, 2007)

    Important Note: Be sure to do a “Save As” on your computer before closing this document.


    ; This form is for fiscal year (FY) 05/06 information only. Information for FY 06/07 will be requested after June

    30, 2007.

    ; Please complete the following questions.

    ; If a question does not apply or cannot be answered, please explain why.

    ; If an answer requires an attachment (i.e., spreadsheet, handout, etc.), please so indicate in the answer


    th; The deadline for submission is June 15, 2007.

    ; Send or drop off completed forms to:

    Alameda County HCSA, Measure A

    c/o Jennifer Chan

    1000 San Leandro Blvd., Ste. 300

    San Leandro, CA 94577

    ; Questions? Contact Jennifer Chan at (510) 618-2016 or

Agency/Program Name: Enter name here

Contact Name: Enter name here Title: Enter title here

Contact Phone #: Enter phone number here Contact E-mail: Enter e-mail address here

Question #1: What is your agency or program’s overall aggregate annual budget?

    Begin answer here

Question #2: What portion of your overall budget is Measure A funding? Include your Measure A allocation

    (i.e. $X) and the percentage.

    Begin answer here

Question #3: List your program and/or agency objectives.

    Begin answer here

    Question #4: Provide information on the process by which Measure A funds you received were allocated within your program.

    Begin answer here

    Question #5: Describe how Measure A funds were used to help meet your program objectives, including how funds were used to help address health disparities. How is the impact of Measure A funds measure in

    achieving your objectives? To the extent possible, quantify workload and performance measures to

    demonstrate how objectives were met.

    Begin answer here

Question #6: List your key accomplishments with respect to the use of Measure A funds.

    Begin answer here

Question #7: Discuss challenges in attaining objectives related to Measure A support, if any. Did any

    objective(s) change from the previous year? If so, what are they and why did they change?

    Begin answer here

Question #8: What would be the impact if Measure A funds were not available? Would programs/services

    be eliminated? If so, describe.

    Begin answer here

Question #9: Were Measure A funds used to leverage (for example, used as a match) to generate additional

    funding? If so, please provide detail including what mechanism was used and how much additional funding

    was generated.

    Begin answer here

Question #10: Is there any other information pertaining to Measure A you would like to share?

    Begin answer here

Report Prepared By: Enter name here

I certify that all information provided in this document is true. I agree and understand that the information provided

    may be used in the Measure A Oversight Committee’s report on expenditures.

Name of Authorizing Agent (if different from report preparer): Enter name here

Print document before signing and dating.

    Signature of Authorizing Agent: ______________________________________________

Date: __________________________

    Thank you!

    Please send or drop off completed reports to:

    Alameda County HCSA, Measure A

    c/o Jennifer Chan

    1000 San Leandro Blvd., Ste. 300

    San Leandro, CA 94577

    The deadline for submission is June 15, 2007. Late submissions will be noted accordingly.

    NOTE: The Measure A Oversight Committee may require follow-up information or

    may request a formal presentation to the Committee.

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