ACHD Certified Healthcare District Program Form

Save and Go instructions:

Before you begin the certification form, ensure that your progress is saved while working on the form:

Click "Log In" button below or “Save Progress” at the end of the form
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This will create a user account and allow you to work on the district’s certification at your own pace without fearing losing progress.

If you have to leave the form before submitting the complete certification form, please make sure to click "Save Progress" at the end of the form before leaving.

Once you return to the form, select the "Log In" button below

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First & Last Name * 🛈

District Name *

Please provide your email address *

Demonstrating Compliance

Districts seeking to demonstrate compliance with the Healthcare District Certification Program must provide evidence of meeting the certification standards, either through a PDF document or a weblink form and as directed below.

There are six sections below, and each section has a list of items that are needed to demonstrate compliance.

Click here for complete Certification Guidelines

Transparency

Completion of Ethics Training

For more information about Ethics Training requirements, click here.

Please provide copies of AB 1234 Training Certificates for all Trustees and Executives. *

Completion of Harassment Prevention Training

For more information about Harassment Prevention Training requirements, click here.

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

Ralph M. Brown Act

For more information about Ralph M. Brown Act requirements, click here.

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

Public Records Request

For more information about Public Records Request requirements, click here.

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

Conflict of Interest Policy

For more information about Conflict of Interest Policy requirements, click here.

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

Fair Political Practices Commission required filers

For more information about Fair Political Practices Commission required filers requirements, click here.

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

State Controller's Compensation Report

For more information about State Controller's Compensation Report requirements, click here.

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

Grant Policy

For more information about Grant Policy requirements, click here.

Provide a copy of the District’s most recently adopted grant policy. If your district does not offer grants, please upload a note stating that grants are not offered. *

Transparency

Website Links

For more information about Website Links requirements, click the links below:

Link to District's mission statement *

Link to Map of District Boundaries *

Link to ACHD's Definition of a Healthcare District *

Link to ACHD.org on District Website *

Link to Trustee, Manager, Staff Contact Information and Board Biographies *

Link to Board Meeting Information *

Link to Enterprise Systems Catalog *

Link to Programs and Services Offered *

Link to Annual Operating Budget *

Link to Financial Audits *

Link to District Election/Vacancy Process *

Link to Healthcare District Authorizing Statute *

Link to Recipients of Grant Funding, if applicable

Link to Municipal Services Review *

Link to your District’s State Controllers Financial Report *

Link to AB 1234 Ethics Certificates for all Trustees and Executives *

Link to Reimbursement policy *

Link to Compensation Policy *

Link to Public Records Request Form *

Link to Financial Reserves Policy *

Link to District Bylaws *

Link to Mobile Friendly Website (Link to the District’s homepage) *

Annual Utilization Report
Annual Services Report
Patient Demographics Report
Quality Reports
Annual Report to the Community
Hospital License

To demonstrate compliance, provide a link to where one of the above six district reports is on the website.

*

Executive Compensation

Policy on Executive Compensation

For more information about the Policy on Executive Compensation requirements, click here.

Provide a copy of the district’s policy on executive compensation. *

Listing of Executive Positions

For more information about the Listing of Executive Positions requirements, click here.

Provide a list of Executive Positions. *

State and Local Agency Reporting

Recent MSR Report

For more information about the Recent MSR Report requirements, click here.

To demonstrate compliance, provide the most recent LAFCO report filed, if completed. If not completed, please indicate that on a note. *

Responses to MSR Report

For more information about the Responses to MSR Report requirements, click here.

To demonstrate compliance, provide the responses to the most recent MSR report filed, if completed. If not completed, please indicate that on a note. *

Financial Reporting

Reimbursable Expenses Policy

For more information about the Reimbursable Expenses Policy requirements, click here.

To demonstrate compliance, provide a copy of the district’s policy on reimbursable expenses for Trustees and employees. *

Signature Authority Policy

For more information about the Signature Authority Policy requirements, click here.

To demonstrate compliance, provide a copy of the district’s signature authority policy for authorizing expenditures and making financial commitments for the district. *

Annual External Financial Audit

For more information about the Annual External Financial Audit requirements, click here.

To demonstrate compliance, provide a copy of the district’s most recent external financial audit. *

Request for Public Funds

For more information about the Request for Public Funds requirements, click here.

To demonstrate compliance, provide a copy of the district’s policy on reviewing and granting public funds. If your district does not offer grants, indicate that on a note. *

Best Practices

CEO Evaluation

For more information about the CEO Evaluation requirements, click here.

To demonstrate compliance, provide proof of completion of an Annual CEO evaluation.

For initial certification, districts must provide the most recent annual evaluation of the CEO.
For renewal applications, districts must provide three years of documentation relating to the annual evaluation of the CEO.

Please note that we do not need the actual CEO evaluation. Board minutes or a signed letter from the Board Chair notating the date(s) of the evaluation is sufficient.

*

Board Self Evaluation

For more information about the Board Self Evaluation requirements, click here.

To demonstrate compliance, provide proof of completion of an annual board evaluation from the previous year, either through the form of adopted Board minutes or a signed letter from the Board Chair notating the date(s) the evaluation was completed.

For initial certification, districts must provide the most recent annual evaluation of the Board.
For renewal applications, districts must provide three years of documentation relating to the annual evaluation of the Board.

Please note that we do not need the actual Board Self Evaluation. Board minutes or a signed letter from the Board Chair notating the date(s) of the evaluation is sufficient.

*

Job Descriptions for Officers of the Board

For more information about the Job Descriptions for Officers of the Board requirements, click here.

To demonstrate compliance, provide a copy of the roles and responsibilities of Board officers or a link to the roles and responsibilities on the district website. *

Best Practices

To demonstrate additional examples of best practices, please provide at least three of the following:

Provide a copy of three of the above documents. *