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DEPARri-LINT OF I-lliWN RESOURCES <br /> DIVISION OF EII ALLTH SERVICES i <br /> I\'aRITI CAROLINA STATE11,11DE FAMILY PLANNt ING PROGRAM � <br /> E y <br /> PERFOP%MICE EVALUATION REPORT <br /> COUNTY.OR REGION or A^:En_r r,— FISCAL YE aQa _ r 0 <br /> 1st 2nd 3rd Q 4th Q FY E_ Rn i <br /> Jul-Sept Oct-Dec Jan-M-r A r-June <br /> FISCAL ACTIVITY .SO C <br /> 1. Amount of Contract Monies Spent Expenditure Objective <br /> Reports Performance <br /> SECOND AND TEiIRD PARTY REIM13URSDIENT ACTIVITY alit <br /> Objective <br /> 2. Visits with Patient Fees Collected 1 <br /> Performance i <br /> i <br /> 3. Persons Billed for through Title XIX 1 Objective ! t t r 17 <br /> erformance <br /> 4. Title XIX Claims Submitted FP 417 Objective o 9 s ann <br /> Performance <br /> S. Persons Billed for through Title XX 1 Objective <br /> Performance <br /> 11A 118 118 118 <br /> 6. Title XX Claims Submitted FP 417 Objective <br /> Performance <br /> CLINIC ACTIVITY -- USERS AND ENCOUNTERS SOURCE <br /> 7. NeW Participants Receiving Medical Family FP 417 Objective <br /> Planning Services Performance <br /> 8. Total Persons Receiving Medical Family 417 Objective pg,, 985 885 fib 7nAA <br /> Plamiing Services Performance <br /> 3 <br /> 9. Total Family Planning Medical Visits FP 417 Objective t 1 il t,qo. <br /> erformance <br /> FA.h!ILY PUM, ING ADVISORY COUNCIL ACTIVITY SOifRC <br /> Minutes of Objective I 1 ( 1 1 4 <br /> 1d. Meetings Held Minutes <br /> Performance <br /> 11, Meeting Attendance Consuners Minutes of Performance <br /> ?dec Performance <br /> 12. 1 i Attendance �- Providers . . ,_ <br />