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Page 3 of 5 <br /> C. Community Organizations <br /> • <br /> List the community organizations that you will work with on this program (i.e., American <br /> Cancer Society, Cooperative Extension) <br /> UNC-CH School of Public Health Department on Aging <br /> American Heart Association Orange County Kellogg Coalition <br /> Cooperative Extension <br /> D./E. Goals and Objectives <br /> All health departments are expected to use the Goal Oriented Evaluation format. Select goals <br /> and objectives from Model Objectives as they relate to your program. Use the format on the <br /> following page to describe your program's goals and objectives. It is expected that the Goals, <br /> Objectives, Terms in Objectives, Method of Measures, and Measure columns will be completed <br /> as part of the Contract Addendum. Results and Analysis are completed as part of the <br /> Performance Report. Complete a separate form for each Program Goal. <br /> Note: Health Promotion Program contracts must include a training objective. For example, "staff <br /> will attend at least one health promotion training endorsed by the Division of Adult Health <br /> within the contract year." <br /> F. Quality Assurance <br /> This program must have a Quality Assurance (QA) plan which includes at least the following <br /> components: Please indicate the components that you have in your Quality Assurance plan by <br /> placing a check,mark after the appropriate item. <br /> • YES <br /> 1. Quality Assurance plan is written and on file. X <br /> 2. Regular QA meetings are planned. X <br /> 3. Appropriate methods of collecting and reviewing program information <br /> will be used (e.g., adult health clinical record review, direct <br /> • observation of program activities, review hypertension.program <br /> policies and procedures, etc.) X <br /> 4. Quality assurance findings and corrective actions taken will be <br /> documented. X <br /> • <br /> 5. Protocols for screening, education, referral/treatment and <br /> follow-up, etc., are established. X <br /> In the appropriate space below, please give the name, title, and degree of person(s) <br /> implementing this contract: <br /> Name Degree <br /> Jerry Ann Gregory, RN Health Promotion Coordinator BSN <br /> Laurel Ellzey, RD Nutrition Program Coordinator MS <br />