ATTACHMENT A

FIRST 5 LA

ORAL HEALTH AND NUTRITION (OHN)

EXPANSION AND ENHANCEMENT PROJECT

PROGRESS REPORT COVER SHEET

I. Contract InformationContract Number:

Agency:
Project Name:
Contract Period(start and end date): / to

II. Report Period

Select Quarter and enter Report Period (date range). Refer to the Report Calendar for dates.

Quarter 1: to / Quarter 2: to
Quarter 3: to / Quarter 4: to

III. Progress Report Check List: Check the items listed below that are being submitted for the report period. Complete and include checked items in the order listed below:

Attachment A: Progress Report Cover Sheet (this document)

Attachment B: Progress Report Matrix

Attachment C: Data Report Form

(Submit when indicated in Report Calendar)

Deliverables attached and listed below

Number attachments sequentially. Label deliverables with assigned “Attachment # ___” in upper right hand corner. Add additional rows as necessary to list all attachments.

Document Number / Document Name/Title, date
Attachment #
Attachment #
Attachment #
Attachment #
Attachment #
Attachment #
Attachment #
Attachment #
Attachment #

IV. Direct Services: Unduplicated Number Served

For each progress report, enter total number of unduplicated individuals served to date in Column A. Enter target number listed in the Scope of Work (SOW) in Column B.

A / B / C
Total Numbers to Date / SOW Target / % of Target to Date (C = A/B)
Unduplicated number of children ages 0-5 receiving preventive services and education*
Unduplicated number of children ages 0-5 receiving therapeutic services
Unduplicated number of Parents/Primary Caregivers receiving education**

*Report on preventive services provided both on and off-site. It is assumed that all children receiving preventive services also receive an educational session as part of their visit.

**Include all parents/caregivers even when demographic information was not collected.

V.Submission Instructions

Please submit and scan entire progress report (signed) as one document, and e-mailit to your assigned Program Officer ( or ) by the due dates indicated in your Report Calendar. Contractors will receive an email confirmation upon receipt of progress report. Note that Program Officer may request additional information.

Please also mail this document, the Progress Report Cover Sheet (Attachment A), with the original signature via regular mail to your assigned Program Officer listed below. It must be postmarked no later than the deadline date.

Reena John
Program Officer
First 5 LA
750 N. Alameda Street, Suite 300
Los Angeles, CA 90012 / Tina Chinakarn
Program Officer
First 5 LA
750 N. Alameda Street, Suite 300
Los Angeles, CA 90012

V. Project Contact Person and Authorized Signature

Project Contact Person (completing report):
Project Contact’s phone number: / Project Contact’s email address:
Name of Authorized Agency Representative:
Original Signature of Authorized Agency Representative:
______
(use blue ink pen) / Date:
______

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