DIVISION OF HIV AND STD PROGRAMS
SERVICE DELIVERY SITE QUESTIONNAIRE
INSTRUCTIONS
Service Delivery Site information allows the Division of HIV and STD Programs (DHSP) to understand the full spectrum of services that your agency offers. This information will be used to negotiate your contract goals, objectives and budgets for the upcoming contract term. In addition, such information is used by DHSP to assess geographic service availability, estimate of need, cost effectiveness and other factors that impact program planning activities.
Please note that service delivery sites must correspond with the information cited under “Service Delivery Site(s)” in your contract. If you are proposing to change service delivery sites during the negotiation process, please notify your program manager.
Please review the following instructions and ensure that all areas of each table are completed.
Table 1 - Complete a Table 1 for each Service Delivery Site. Ensure that you assign a site number for each service delivery site because subsequent tables request information about each site-by-site number.
Table 2 - Complete one Table 2. For each service delivery site, project the number of unduplicated clients to be served and hours to be provided under this contract.
I acknowledge that the Service Delivery Site Questionnaire has been completed to the best of my knowledge and may be used during the contract negotiation process and for program planning activities.
Agency Head or Designee Signature Date
Print Name Title
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DIVISION OF HIV AND STD PROGRAMS
SERVICE DELIVERY SITE QUESTIONNAIRE
SERVICE DELIVERY SITES
Table 1
Site # of
1. Agency Name:
2. Executive Director:
3. Address of Service Delivery Site:
City State Zip
4. In which Service Planning Area is the service delivery site:
One: Antelope Valley Two: San Fernando Valley
Three: San Gabriel Valley Four: Metro Los Angeles
Five: West Los Angeles Six: South Los Angeles
Seven: East Los Angeles Eight: South Bay
5. In which Supervisorial District is the service delivery site:
One: Supervisor Molina Two: Supervisor Ridley-Thomas
Three: Supervisor Yaroslavsky Four: Supervisor Knabe
Five: Supervisor Antonovich
6. Based on the number of [click here and enter the unit of service for the service category] to be provided at this site, what percentage of your allocation is designated to this site?
DIVISION OF HIV AND STD PROGRAMS
SERVICE DELIVERY SITE QUESTIONNAIRE
CONTRACT GOALS AND OBJECTIVES
Table 2
Number of ENTER SERVICE CATEGORY Contract Goals and Objectives by Service Delivery Site(s)
Please note: “Number of Clients” will refer to the number of unduplicated clients.
Contract Goals and Objectives / (enter goal) / (enter goal) / (enter goal) / (enter goal) / (enter goal)Service
Unit / No. of Clients / No. of Hours / No. of Clients / No. of Hours / No. of Clients / No. of Hours / No. of Clients / No. of Hours / No. of Clients / No. of Hours
Site # 1
Site # 2
Site # 3
Site # 4
Site # 5
Site # 6
Site # 7
Site # 8
Site # 9
Site # 10
TOTAL
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