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Orange County Health Department <br />4 <br />FY 2007 Community Health Center Grants <br />ST:~'VI:MAItY OF EVALUATION CRITERIA & BASELINE DATA <br />Instructions: This form must be completed and submitted with your grant application to be considered <br />for community health grant funding. IF THIS FORM IS NOT COMPLETED YOUR REQUEST <br />WILL NOT BE CONSIDERED FOR FUNDING. <br />Patients Served by Project <br />Report the current number of patients or users served by the project (this number will be 0 for the <br />creation of new services) and the anticipated number of patients or users who will be served by the <br />proposed project through June 30, 2007. Patients/Users are the number of unduplicated patients for all <br />project initiatives funded by the Community Health grant. <br /> Baseline as of <br />1/1/2007 date Target to be Served <br />b 6/30/07 <br />Total Unduplicated Patients /Users 0 80 <br />Evaluation Criteria <br />Summarize the evaluation criteria from your application in the table below. You need to complete both <br />this table and the evaluation section in the grant application. <br />Evaluation Criteria Baseline Values/Measures Target to Be Reached <br /> as of 1/1/2007 date b 6/30/07 <br />Example: <br />To increase behavioral health cap°e 3 encounters/month 17 encounters/month <br />encounters for uninsured patients from 3 <br />to 17 encounters per month <br />1. Recruit and employ temporary No temporary primary care .4 FTE FNP <br />personnel to begin Primary Care services personnel at SHSC .5 FTE Lab Tech <br />at SHSC .5 FTE PHN <br /> .4 FTE Nursing Assistant <br /> .5 FTE Management <br /> Support <br />2. Increase primary care clients at SHSC 0 patients 80 patients <br />from 0 to 80 <br />3. Increase primary care encounters to 0 encounters 128 <br />SHSC clients from 0 to 128 <br />4 <br />