Form rh5

OMB No. 0915-xxxx

Expiration Date:

Office of Rural Health Policy: Rural Health

Community-Based Grant Programs

Performance Improvement and Measurement System (PIMS) Database

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-xxxx. Public reporting burden for this collection of information is estimated to be 4 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

Network Development Planning Grant Program

Table 1: NETWORK

1	Number of member organizations in the consortium / network.	Number
2	Type(s) of member organizations in the consortium / network. (Check all that apply)	Selection list
	Hospital
	Critical Access Hospital
	Rural Health Clinic
	Free Clinic
	Private Practice
	Community Health Center
	Migrant Health Center
	Health Department
	AHEC
	University
	School District
	Social Services Organization
	Non-profit organization
	Faith-based organization
	For-profit business
	Other

Table Instructions: Networks

Please provide the number of organizations in the consortium or network for your project and the type(s) of member organizations; check all that apply. Please refer to the detailed definitions for consortium/networks.

Table 2: SUSTAINABILITY

3	Has a sustainability plan been developed using sources of funding besides grants?	Y/N
4	Type(s) of sources of funding for sustainability: (Check all that apply)	Selection list
	Program revenue
	In-kind
	Member fees
	Other grants
	Other
	None

Table Instructions: Sustainability:

Please identify if a sustainability plan has been developed using funding sources other than grants and then select the type(s) of sources for that funding. Please check all that apply. If your grant project has not received any additional funding, please type N/A for not applicable.

Table 3: NETWORK DEVELOPMENT

5	Within six (6) months of the end of the original Planning Grant project period:	Selection list : Yes / No / In Progress
	a) Did the Network Members develop a formal Board of Directors that is composed of a representative from each network member organization?
	b) Did the Network Members sign a formal, legally binding agreement to work as one entity for a common goal?
	c) Did the Network Members develop by-laws?
	d)  Did the Network Members complete a strategic plan or develop a timeline to complete a strategic plan?

Table Instructions: Network Development

Please select Yes, No or In Progress for each performance measure question.

Definition of Key Terms for Rural Health Community-Based Grant Programs

Charity Care: any services provided free of cost or reimbursement

Consortium/Network: Comprised of at least 3 separately owned organizations that are working together towards the project’s goals and objectives. Specifically respond only for the formal member organizations, for the purposes of your grant project.

Medical Home: provides patients with continuous access to services.

Target Population: The population identified by the grant project to receive services.

Total Encounters: The number of documented services provided to all individuals.

Total Non Duplicated Encounters: The number of unique individual users who have received documented services.

Underinsured: A person who has health insurance but face significant cost sharing or limits on benefits that may affect its usefulness in accessing or paying for needed health services and/or who may lack continuous access to health insurance coverage.

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