Section I: Local Health Evaluation Report/Questionnaire
This questionnaire must be completed online through the State's
Portal ( Instructions
for access to LHER system through State's Portal).
The questionnaire is designed with either yes/no or scaled
responses. The scaled responses are based on the level of completion.
The online system will automatically award points to each
answer in Section I that will be computed by subsection and
in total once the report has been submitted. The information
and data provided, will be maintained
in a NJDHSS centralized database and will serve as a partial
resource for determining baseline capacities and performance
and to monitor and evaluate trends. The scoring system has
been developed in order to provide information on strengths
and weaknesses for the purpose of process improvement and
system development.
Simple 'yes' and 'no' answers are valued at 0 or 3 points, 0
for a 'no' answer and 3 for 'yes'. Percentages (where provided),
refer to the level of completion or degree of activity for
that item. Specifically, the scaled responses are based on
the following conditions and will be awarded points as indicated:
Not Met, 0 to 25 percent completion=0 points
Partially Met, 26 to 50 percent completion=1 point
Substantially Met, 51 to 75 percent completion=2 points and
Met, 76 to 100 percent completion=3 points
Responses to questions in Section I (the Questionnaire) may
be corrected during completion. However, once the information
has been submitted, it cannot be changed. Completed forms
are available for review or printing.
Sample Questionnaire (This blank form can be printed as a hard copy)
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Section II: Budget by Funding Source
This form must be completed online through the State's
Portal ( Instructions
for access to LHER system through State's Portal).
You will also find a Glossary of Terms which provides further detail for
both the Activity Categories as well as the Funding Sources. Please note that the definitions of activity and funding categories have changed from the previous year. Please review the glossary prior to preparing the report.
Please print a copy of the Budget by Funding source chart prior to entering the data into the Portal.
This will allow time to prepare your data for entering. Once the information has been submitted, it cannot be changed.
Sample for Budget by Funding Source (This blank form can be printed as a hard copy)
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Section III: Board of Health Registration (BOH)
This form must be completed online through the State's
Portal ( Instructions
for access to LHER system through State's Portal).
Each Health Officer is responsible for gathering and entering the information for all the boards, including all contracting boards, within his or her jurisdiction.
For departments serving multiple municipalities but have a single board of health, information related to that board should be entered once using the municipality location where the department is physically located. For example, when a county health department or regional health commission is answerable to a centralized board of health (even though participating municipalities may convene governance meetings for their own purposes) information related to the board of health providing the health department’s ultimate authority is entered once.
County health departments and multi-municipal departments not having a constituted single board of health must enter information for all the individual boards within its jurisdiction.
All information entered on the Board of Health Registration on-line forms is to be current as of the date of completion. This will allow newly appointed board members to be registered even though their appointment may have occurred subsequent to January the first.
Sample for BOH (This blank form can be printed as a hard copy)
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Section IV: Supplemental Forms
All the forms in Section IV are in fillable format. Please complete all forms and save.
This section consists of various supplementary documents identified
by one of the following corresponding letters:
LH2 A is Health Officer
Certification
LH2 B is the Best Practices,
Capacity and Performance form
LH2 C is the Program
Management and Leadership Staff form
LH2 D is the Record
of Employee Continuing Education and Training Contact Hours form
LH2 E is the Community
Organizations and Agencies Working in Partnership form
LH2 F is Board of Health Approval Form
Form B: Core Activities
Information should be provided for all Core Activities
(Form B, Sections IA through IE) unless they have been formally
waived. Do not use "Not Applicable (N/A)" if an activity
has not been provided and has not been waived. Each line of
data within each activity provided by your health department
requires an entry (See GENERAL, below.). If there are no
participants/services in a given category, indicate that
with a zero. Please do not leave any spaces blank!
Form B: Elective Activties
Elective activities which are being provided should be
completed in full. It is not necessary to put N/A next to
those elective activities not being provided.
Form B: General
Services provided by contracting agencies or individuals
such as health educators and VNA's or Home Health Agencies
which are directly funded by the local health department
should be accounted for and reported where applicable (e.g.
STD, Cancer, TB, Health Promotion).
Several activities request information on the number of
unduplicated users and the number of total visits. For
example, 1,500 visits for a CHC may have been recorded;
however, of those 1,500 visits, only 1,000 children were
seen. The number of unduplicated users is 1,000; the number
of total visits 1,500.
 After completing section IV, please send all forms (A, B, C, D, E, and F) to the
Department at:
New Jersey Department of Health and Senior Services
Local Health Evaluation Report
Office of Public Health Infrastructure, 4th fl.
PO Box 360,
Trenton, NJ 08625
Attn: Adrienne Brown
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