Attachment C

Page 1 of 5

2017–18 Annual Year-End Program Report
for Tobacco-Use Prevention Education Program
County Technical Assistance and Leadership Funds
COVER PAGE
This Annual Year-End Program Report must be received in the Coordinated School Health and Safety Office no later than
September 30, 2018. Delays in receipt of this report will delay release of the final 25 percent of allocated funds.
County Office of Education Name: / Submission Type: / Original / Date:
County/District Code (7 digits): / Revision / Date:
Contact Person: / E-mail: / Phone:

Check each item included with this report. Each item listed below mustbe included with this Cover Page to be considered complete. Incomplete reports will delay therelease of funds.

Year-End Program Report (pages 2–3)
Local Educational Agency (LEA) Assistance Provided
for 2017–18 (page 4)
Collaboration Engaged infor 2017–18 (page 5) / Scope of Work (Attachment B)
Annual Fiscal Report and Carryover Calculation
(Attachment D)
Carryover Request Justification (if applicable)
(Attachment E)

Mail all documents listed above to:For inquiries, contact:

Rachael Gutierrez, Staff Services AnalystRachael Gutierrez
Coordinated School Health and Safety OfficeTelephone: 916-319-0196
California Department of EducationFax: 916-319-0218
1430 N Street, Suite 6408E-mail:
Sacramento, CA 95814-5901
2017–18 Annual Year-End Program Report
for Tobacco-Use Prevention Education Program
County Technical Assistance and Leadership Funds
Briefly address the following questions. Attach additional pages as necessary.
  1. During the past year, to what extent were the key activities listed on the submitted Scope of Work document effectively accomplished within the identified timeline?

Check One / Based on the number of activities listed on the Scope of Work:
All activities accomplished within timeline (100 percent)
Most activities accomplished within timeline (60 to 99 percent)
Some activities accomplished within timeline (1 to 59 percent)
No activities accomplished within timeline
2.If all activities were not accomplished as planned, what were the circumstances preventing the county office of education (COE) from accomplishing them?
3.Describe any major tobacco-use prevention accomplishments that can be attributed to the leadership of the COE during the reporting period.
4.During the reporting period, did the COE participate in the local county health department tobacco control coalition?
Yes No
5.If the response to question 4 above was “Yes,” was the COE provided opportunities to actively contribute to discussions and to participate in tobacco control coalition activities?
Yes No
6.If the response to question 5 above was “Yes,” describe thetobacco control coalition activities to which the COE contributed.
7.Other comments or recommendations:
Completed by (Name/Title): / Date: / Telephone:

Attachment C

Page 1 of 5

2017–18 Annual Year-End Program Report
for Tobacco-Use Prevention Education Program
County Technical Assistance and Leadership Funds
LOCAL EDUCATIONAL AGENCYTECHNICAL Assistance Provided BY THE County office of education for 2016–17
On these pages, list the names of all LEAs in the county and indicate with an “X” the services that were provided to the LEA during the 2017–18 grant period. Check the item of service provided in the boxes on the chart. Add additional rows as needed.
Local Educational Agency Name / Tobacco-Use Prevention Education Technical Assistance Provided / Tobacco-Use Prevention Education Grant Report Reviews Conducted / Other Tobacco-Use Prevention Education Related Activities (List)
California Healthy Kids Survey (CHKS) Administration / CHKS Data Analysis / CHKS Results Reporting / Preparing Reports / Tobacco-Free School Policy / Curriculum Selection/ Implementation / Youth Development Projects / Cessation/ Interventions / Tobacco-Use Prevention Education Online Annual Report / Grant Progress Report
2017–18 Annual Year-End Program Report
for Tobacco-Use Prevention Education Program
County Technical Assistance and Leadership Funds
COLLABORATION ENGAGED IN BY THE COUNTY OFFICE OF EDUCATION for 2016–17
On these pages, list the names of any local governmental or communityagencies in the county with which the COE may have collaborated and indicate with an “X” thecollaborative activities.
Agency Name / CHKS Administration / Reviewing Grant Progress Reports / Tobacco-Free School Policy / Curriculum Selection/ Implementation / Youth Development Projects / Cessation/ Interventions / Other (Describe) / Other (Describe) / Other (Describe)