Forms

 

If you can’t locate the form you are looking for, please contact us and we will help you find what you need.

 NOTE: all reimbursements require original receipts to be mailed to the CCLHDN treasurer.   You can email (treasurer@cclhdn.org) a PDF of the reimbursement form + receipts, but originals must follow in the mail.

For reimbursements,  please tape/paste all original receipts onto a blank sheet of paper, and send to:

CCLHDN Treasurer/ April Jurisich

Shasta County Public Health Department

2660 Breslauer Way, Redding, CA 96001

 

Please allow up to 45-days for processing your reimbursement requests. For all Network related travel activity, CCLHDN follows State guidelines on travel reimbursement.  Please click here to review State travel reimbursement allotments.

PEER EXCHANGE

Peer Exchange Travel Reimbursement Form  – for health department staff who traveled to visit a host site AND for host-site Peer Exchange lunch reimbursement.

Peer Exchange Matching Checklist- HOST

Peer Exchange Matching Checklist – MENTEE

MEMBERSHIP

2016-2017  CCLHDN Membership Form

W-9 Form For Membership Dues Payment

Form 590 for Membership Dues Payment

MISCELLANEOUS

CCLHDN Letterhead

BOARD AND STAFF REIMBURSEMENTS

Travel Reimbursement Form

Expense (non-travel) Reimbursement Form