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ACHD Certification Submission Form PART 1

Please complete all requirements below. If you have difficulty submitting all required documents via our website, please email the documents to Michelle Rouse.

Fields marked with an * are required.

Please verify that you have checked the “I'm not a robot” checkbox.

Provide copies of AB 1234 Training Certificates for all Trustees and Executives.

20MB max

Provide copies of Sexual Harassment Prevention Training Certificates for all Trustees and Executives and a policy for all nonsupervisory employees to receive their mandated training

20MB max

Provide a copy of the Board’s Policy on the Brown Act.

20MB max

Provide a copy of the Board’s Policy on public records requests.

20MB max

Provide a copy of the Board’s conflict of interest policy

20MB max

Provide a list of all designated Form 700 filers for your District.

20MB max

Please provide a copy of the report submitted to the State Controller’s Office.

20MB max

Provide a copy of the District’s most recently adopted grant policy. 

20MB max

Please note, if you need additional space to write, the box below expands.

Please provide links to the following sections of your website. 

  • District’s mission statement 
  • Map of District Boundaries
  • ACHD’s Definition of a Healthcare District
  • Link to ACHD.org on District Website 
  • Trustee, Manager, Staff Contact Information and Board Biographies
  • Board Meeting Information
  • Enterprise Systems Catalog
  • Programs and Services Offered
  • Annual Operating Budget
  • Financial Audits • District Election/Vacancy Process
  • Link to Healthcare District Authorizing Statute
  • Recipients of Grant Funding 
  • Municipal Services Review
  • Link to your District’s State Controllers Financial Report
  • AB 1234 Ethics Certificate for all Trustees and Executives
  • Reimbursement policy 
  • Compensation Policy
  • Public Records Request Form
  • Financial Reserves Policy
  • District Bylaws
  • Mobile Friendly Website (Link to the District’s homepage)
  • Website Transparency (one of the following) 
    • Annual Utilization Report 
    • Annual Services Report
    • Patient Demographics Report
    • Quality Reports
    • Annual Report to the Community
    • Hospital License


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