Spreadsheet: 0173a8a7-f11a-4be0-a918-0fd3b81ff0c9
Sheet: Sheet1

Unnamed: 0 | Community Living, Aging Division, Wyoming Department of Health | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5
 | Fiscal Year 2013 Grants Quarterly Program Report Form
 | AoA Title III-C2 Congregate Meal Program
 | Grantee:
 | Address:
 | City, State, Zip:
 | Phone:
 | [NAME]:
 |  | County:
 | Quarter covered by this report: |  | October, November & December 2012
 | Per contractual agreement, grantees must submit quarterly program reports to the Aging Division to provide information on the progress of the funded program.  The questions refer directly to the FY2013 grant application that was submitted to the Aging Division.  The program report for the First Quarter of Fiscal Year 2013 is due on or before January 25, 2013.
 | *This form must be computer generated. No typewritten or hand-written documents will be accepted.
 | *Please respond to each question.  If there is no answer to a question, write "none" or place a "0" in the space provided.
 | Signature of Director |  | (SIGN IN BLUE INK) | Date
 | Print Name
 | IMPORTANT: Quarterly program reports for First Quarter of Fiscal Year 2013 must be received by the Aging Division on or before January 25, 2013.  Failure to submit the required reports by the deadline will delay future payments.  Send the original quarterly program report to:  Aging Division, Wyoming Department of Health, 6101 Yellowstone Rd., [NAME] 186A, Cheyenne, WY  82002.  NO FAXES OR EMAILS WILL BE ACCEPTED.
 | I.  CLIENT OUTCOMES: For the service categories below, please answer the questions about services provided during the First Quarter (October 1, 2012 - December 31, 2012).  Please attach a copy of the SAMS report that validates this data.
 | Home Delivered Meals-Required
 | CLIENT OUTCOME - Individual clients will improve health by consuming a meal that meets the dietary guidelines and dietary reference intakes as specified in AoA and approved by [NAME].
 | 1. How many eligible meals did you provide during the First Quarter (10/01/2012 - 12/31/2012)? (Should equal financial report) Report from SAMS (In SAMS run Agency Summary Report: 2013 Quarterly - Unduplicated count by Care Program - no change of status included)
 | 2. How many eligible meals did you provide YTD (10/01/2012 - 12/31/2012)? (Should equal financial report) Report from SAMS (In SAMS run Agency Summary Report: 2013 Quarterly - Year to Date Totals C2)
 |  |  | Quarterly running total: |  | 0
 | Nutrition Education-Required
 | CLIENT OUTCOME - Individual clients will be more knowledgeable about nutrition and will apply this knowledge to their current nutrition habits.
 | 1. How many unduplicated clients received Nutrition Education during the First Quarter (10/01/2012 - 12/31/2012)?  Please attach a copy of the SAMS report. (In SAMS run Agency Summary Report: 2013 Quarterly - Unduplicated count by Care Program - no change of status included)
 | 2. How many total units of Nutrition Education did you provide during the First Quarter (10/01/2012 - 12/31/2012)? Please attach a copy of the SAMS report. (In SAMS run Agency Summary Report: 2013 Quarterly - Unduplicated count by Care Program - no change of status included)
 | Case Management-Required
 | CLIENT OUTCOME - Individual clients at risk for low nutrient intake and related health problems will receive services and information to improve or maintain their nutritional risk score.
 | 1. Based on the number of unduplicated clients who received at least one eligible meal during the First Quarter (10/01/2012 - 12/31/2012) , how many have a nutritional risk score of:
 | Please attach a copy of the SAMS report. (In SAMS run Service Delivery Profile - Cross Tab: 2013Quarterly - Home Delivered Meals nutritional risk counts) |  |  | High
 |  |  |  | Low
 |  |  |  | Don't Know
 | Nutrition Counseling
 | CLIENT OUTCOME - Individual clients will receive one-on-one counseling provided by a Registered Dietitian to improve nutritional status.
 | 1. How many unduplicated clients received Nutritional Counseling during the First Quarter (10/01/2012 - 12/31/2012)? Please attach a copy of the SAMS report. (In SAMS run Agency Summary Report: 2013 Quarterly - Unduplicated count by Care Program - no change of status included)
 | 2. How many total units of Nutritional Counseling did you provide during the First Quarter (10/01/2012 - 12/31/2012)? Please attach a copy of the SAMS report. (In SAMS run Agency Summary Report: 2013 Quarterly - Unduplicated count by Care Program - no change of status included)
 | II. PROGRAM GOALS: Please provide progress on the actions steps listed for each program goal and answer the questions about services provided during the First Quarter (October 1, 2012 - December 31, 2012). Please attach a copy of the SAMS report that validates this data.
 | PROGRAM GOAL #1 -Maintain or increase the number of unduplicated clients receiving AoA Title III-C2 services (care program) by 1% during the grant period of October 1, 2012, through September 30, 2013.
 | A. How many unduplicated clients received at least one eligible meal during the First Quarter (10/01/2012 - 12/31/2012)? Please attach a copy of the SAMS report. (In SAMS run Agency Summary Report: 2013 Quarterly - Unduplicated count by Care Program - no change of status included)
 | Please establish a baseline by reporting the number of unduplicated clients that received a meal between the period of May 1, 2011 through April 30, 2012. Please attach a copy of the SAMS report. (In SAMS run Agency Summary Report: 2013 Quarterly - Unduplicated count by Care Program - no change of status included) |  |  | Baseline:
 | [NAME] increase or decrease compared to the baseline data. |  |  | Percent Change:
 |  |  | Percent Change Based on Previous Quarter:
 |  |  |  | Percent Change YTD:
 | C. Do all C2 clients have a current AGNES and have they been entered into the SAMS program for the period of 10/01/2012 - 12/31/2012?
 | Yes | No
 | PROGRAM GOAL #2 - Increase the number of unduplicated clients living below the 2012 Federal Poverty Level receiving AoA Title III-C2 services by 3% during the grant period of October 1, 2012, through September 30, 2013.
 | A. How many unduplicated clients living below the 2012 Federal Poverty Level received Title III-C1 services during the First Quarter (10/01/2012 - 12/31/2012)? Please attach a copy of the SAMS report. (In SAMS run Agency Summary Report: 2013 Quarterly - Clients with poverty status yes - does not include change of status)
 | Please establish a baseline by reporting the number of unduplicated clients who live below the 2012 Federal Poverty Level that received a meal between the period of May 1, 2011 through April 30, 2012. Please attach a copy of the SAMS report. (In SAMS run Agency Summary Report: 2013 Quarterly - Clients with poverty status yes - no change of status included, for the period between the dates listed above) |  |  | Baseline:
 | [NAME] increase or decrease compared to the baseline data. |  |  | Percent Change:
 |  |  | Percent Change Based on Previous Quarter:
 |  |  |  | Percent Change YTD:
 | C. Report the percentage of clients living at or below the 2012 Federal Poverty Level as compared to the total number of clients registered in the Title III C2 program.
 | D. Did you report all client information in the Senior Assistance Management System (SAMS) by the 8th working day of the month following service provision?
 | Yes | No
 | PROGRAM GOAL #3 - Increase the number of registered clients who live alone by 1% during the grant period of October 1, 2012, through September 30, 2013.
 | A. How many unduplicated clients who live alone received Title III-C2 services during the First Quarter (10/01/2012 - 12/31/2012)? Please attach a copy of the SAMS report. (In SAMS run Agency Summary Report: 2013 Quarterly - clients with live alone status yes - does not include change of client status)
 | Please establish a baseline by reporting the number of unduplicated clients who live alone that received a meal between the period of May 1, 2011 through April 30, 2012. Please attach a copy of the SAMS report. (In SAMS run Agency Summary Report: 2013 Quarterly - clients with live alone status yes - does not include change of clients status for the period, between the dates listed above) |  |  | Baseline:
 | [NAME] increase or decrease compared to the baseline data. |  |  | Percent Change:
 |  |  | Percent Change Based on Previous Quarter:
 |  |  |  | Percent Change YTD:
 | C. Report the percentage of clients living alone as compared to the total number of clients registered in the Title III C2 program.
 | D. Did you report all client information in the Senior Assistance Management System (SAMS) by the 8th working day of the month following service provision?
 | Yes | No
 | PROGRAM GOAL #4 - Older Americans Act requirements to serve clients with hunger and food insecurity are being met. Survey of participants shows 90% are satisfied with the Home Delivered Nutrition Program. Data is collected via the Nutrition Screen to address the percentage of clients with food insecurity and hunger issues. Survey will be provided on the quarterly reports during the grant period of October 1, 2012, through September 30, 2013.
 | A. Results of the client survey questions that were provided. Please record results on the sheet provided and attach to the back of the 4th quarter program report.
 | B. Report the number of unduplicated clients with food insecurity during the First Quarter (10/01/2012 - 12/31/2012). Please attach a copy of the SAMS report. (In SAMS run Service Delivery Profile - Cross Tab: 2013 Quarterly - HDM poverty & nutritional risk counts)
 | C. Report the number of unduplicated clients with hunger during the First Quarter (10/01/2012 - 12/31/2012). (Based on the poverty status in Program Goal #2) |  |  |  | 0
 | Percentage of clients with food insecurity compared to the total number of clients:
 | Percent increase or decrease of clients with food insecurity (YTD):
 | Percent increase or decrease of clients with food insecurity (Quarterly):
 | Percentage of clients with hunger compared to the total number of clients:
 | Percent increase or decrease of clients with hunger (YTD):
 | Percent increase or decrease of clients with hunger (Quarterly):
 | PROGRAM GOAL #5 - Maintain cost efficiency by controlling raw food costs at or below 125% of the statewide average based upon the average for the previous quarter.
 | A. Did you complete the Quarterly Meal Costing Report to submit with the quarterly program and financial report?
 | Yes | No
 |  | Previous quarter's average raw food cost:
 |  |  | Raw food cost this quarter:
 |  |  | Average raw food cost for facility YTD:
 | B. The percent above or below the statewide average raw food cost that your facility expends.