Spreadsheet: 078d27ec-a29d-42e0-a92a-e16793bc5a41
Sheet: Sheet1

Unnamed: 0 | WYOMING DEPARTMENT OF HEALTH
 | AGING DIVISION, COMMUNITY LIVING SECTION
 | Instructions for Fiscal Year 2013 AoA Title III-D Disease Prevention and Health Promotion
 | QUARTERLY PROGRAM REPORT
 | These Instructions are designed to help you complete the required Program forms. The first time you use the form, please make sure you open the form on the “Qtr 1” tab.  Make sure to check each quarter that you are on the correct tab.
 | The cells available to enter information into have been shaded yellow or gray.
 | GRANTEE
 | Legal Corporate name of grantee and contact information only need to be entered in the first (1st) quarter Program and Fiscal Reports. This information will be automatically merged to the 2nd, 3rd, and 4th quarter reports/worksheets.
 | QUARTERLY REPORT PERIOD
 | This box is filled automatically and corresponds to the quarterly tab.
 | GRANT COVERED BY THIS REPORT
 | The grant covered by the report is listed at the top of the report in the third line of the heading.   A separate report must be completed for each grant.
 | NOTE: All information must be computer generated in Excel.  No typed or hand-written documents will be accepted.  The spreadsheet is designed to allow information to be carried forward from the grant application and then quarter-to-quarter.
 | TYPE NAME
 | Enter the name of the director who is certifying this document.
 | SIGNATURE OF DIRECTOR
 | Signature (in BLUE ink) of the director is required.  [NAME] reports will not be accepted.
 | DATE
 | Enter the date the report was signed.  Enter the date in MM/DD/YY format.  Undated reports will not be accepted.
 | Faxed and emailed copies will not be accepted.  The original signed and dated report must be submitted to the Aging Division, Wyoming Department of Health, by the required due date.
 | I. CLIENT OUTCOMES
 | Each of the sub-service category of Health Services for the FY2013 Title III-D Grant are listed.  To the right of the service category there is a green box.  This information in the green boxes reflect services your agency will be provided under this grant for FFY 2013.  [NAME] "YES" in the green box for the sub-service you will provide or "NO" for service will NOT be provided under this grant.  For each category that shows "YES", you will need to complete the questions and provide SAMs data for services you had provided during the reporting period.
 | NOTE: The required survey questions and response formats have been provided for you in the Survey Questionnaire and Survey Summary Tabs, after the Third Quarter Program Report tab.  The survey MUST be COMPLETED by August 31, 2013.  The survey results must be reported in the Fourth Quarter Program Report by October 15, 2013. You may add additional questions to the survey to collect statistical information you need for your own report.
 | II. PROGRAM GOALS
 | In this section you will report on the progress(es) in accordance with the program goals listed on the FY2013 Grant Application.  In the yellow boxes, please provide goal(s), action step(s), and progress(es) you have achieved during the reporting quarter, in support of your program.  A brief recap of unmet goal(s)/activity(ies) and the highlights of additional activity(ies) you have completed during this quarter. Below the yellow box, there are additional questions about numbers and units of services offered during the reporting period. This information can be obtained from the quarterly SAMs report.
 | III. OTHER
 | This box is optional.  Please share any additional program information, comments, and suggestions on activities or events that have impacted or will impact this grant, in this column.
 | NOTE: The yellow boxes under sections II and III are limited to 1000 characters (including spaces).  If you try to exceed the allowed space, an error box will open in Excel.  Typed and hand-written reports will not be accepted.