2021-2022 Community Health Contract-Grant: Q3 Impact Report

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Organization Name:* This field is required.
Please use the entity's legal name
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Program Title:* This field is required.
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Person submitting the report:* This field is required.
Name
Title
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Ages: List the percentage and total number served of your program participants’ ages who received services during this reporting time frame:* This field is required.
Percentage served
Total Number Served
Children (infants to 12)
Young Adults (13-17)
Adults (18-60)
Seniors (60+)
Unknown
Children (infants to 12)
Young Adults (13-17)
Adults (18-60)
Seniors (60+)
Unknown
Percentage served
Total Number Served
Percentage served
Total Number Served
Percentage served
Total Number Served
Percentage served
Total Number Served
Percentage served
Total Number Served
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Gender: List the percentage and total number served of your program participants’ gender identification who received services during this reporting time frame:* This field is required.
Percentage served
Total Number Served
Female
Male
Non-binary
Unknown
Female
Male
Non-binary
Unknown
Percentage served
Total Number Served
Percentage served
Total Number Served
Percentage served
Total Number Served
Percentage served
Total Number Served
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Income: List the percentage and total number served of your program participants’ income limit category of those who received services during this reporting timeframe:* This field is required.
Percentage Served
Total Number Served
Extremely Low-Income (ceiling of $32,100)
Very Low (50%0 Income (ceiling of $53,500)
Low (80%) Income (ceiling of $85,600)
Higher than listed limits
Unknown
Extremely Low-Income (ceiling of $32,100)
Very Low (50%0 Income (ceiling of $53,500)
Low (80%) Income (ceiling of $85,600)
Higher than listed limits
Unknown
Percentage Served
Total Number Served
Percentage Served
Total Number Served
Percentage Served
Total Number Served
Percentage Served
Total Number Served
Percentage Served
Total Number Served
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How many District residents directly benefited (participant/client)from this program in this reporting quarter? * This field is required.
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Please provide the Goal 1 statement from your application. Discuss the actions within each objective and provide your outcome data accordingly.* This field is required.
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Please provide the Goal 2 statement from your application. Discuss the actions within each objective and provide your outcome data accordingly.(if applicable, otherwise note N/A)
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Participant Success Story:
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Participant Success Story:
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Please describe how the Fallbrook Regional Health District’s Community Health Contract - Grant investment toward this program was acknowledged during this reporting timeframe.* This field is required.
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Please upload one example of how the District's support for this program was publicly acknowledged.
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Please upload a copy of the program budget you submitted with the application. Fill in the Q3 column demonstrating the current utilization of grant funds.* This field is required.
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Please explain any significant differences in budget or services during this quarter. What if any changes were made to address programming challenges.
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Please sign your form:
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