Templates and Forms

On this web page you can find information on the Office of Health Equity and Racial Justice’s (HERJ) technical assistance resources to support the implementation of the Community Health Ambassadors Program. If you have any questions, please email healthambassadorproject@aacounty.org


  • Performance Measures Reporting Form:
    Complete this form each month to report your completed activities.
  • Relationship Management Form:
    Complete this form when your organization has developed a new partnership. 
  • FY25 CHA Purchase Request Form:
    Complete this form to submit a purchase request to the HERJ team. After submitting the form, a HERJ team will notify you that your request has been received and is under review. Please allow 1-3 business days for review and approval to purchase the requested items. 
  • FY25 CHA Technical Assistance Request Form:
    Complete this form to submit a technical assistance request. Technical assistance requests include but are not limited to program planning, financial reporting, training for staff members, etc. Please allow 1-2 business days to review your request and for a staff member to contact you regarding your request.