Form 5 Network Development Planning

OMB No. 0915-0319

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 0915-0319. Public reporting burden for this collection of information is estimated to be 1 hour 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.

Rural Health Network Development Planning Grant Program

Table 1: ACCESS TO CARE

Table Instructions: Access to Care

Information collected in this table provides an aggregate count of the number of counties within the service area.

Number of counties served

• Denotes the number of counties served through the program. Please include entire, as well as partial counties served through the grant program. If your project is serving only a fraction of a county, please count that as one (1) county.

1	Number of Counties: (If you serve a sub-county area please count this as 1)	Number/DK
	Number of counties served in program

Table 2: NETWORK

Table Instructions: Network

Please identify the types of formal member organizations in the consortium or network by non-profit and for-profit status for your program. Please indicate a number for each category. Please provide the total number of member organizations in the consortium or network. Then, out of the total number of organizations in consortium/network, please provide the total number of new member organizations acquired within the budget year.  Please refer to the detailed definitions for consortium/networks, as defined in the program guidance. Please select the focus area(s) of the consortium/network for the budget yea

2	Type(s) of Member Organizations in the Consortium / Network	Number
Non-Profit Organization:	Area Health Education Center (AHEC)
	Community College
	Community Health Center
	Critical Access Hospital
	Faith-based organization
	Free Clinic
	Health Department
	Hospital
	Migrant Health Center
	Private Practice
	Rural Health Clinic
	School District
	Social Services Organization
	University
	Other – Specify Type:
	TOTAL for Non-Profit Organization	Number (automatically calculated by the system)
For-Profit Organization:	Community College
	Community Health Center
	Critical Access Hospital
	Faith-based organization
	Organization Free Clinic
	Health Department
	Hospital
	Migrant Health Center
	Private Practice
	Rural Health Clinic
	School District
	Social Services
	University
	Other – Specify Type:
	TOTAL for For-Profit Organization	Number (automatically calculated by the system)
3	Total Number of Member Organizations in the Consortium/Network:	Number
4	Total Number of New Member Organizations in the Consortium/Network: If applicable, check the area of focus your network was established to eventually impact.	Number
5	Focus Area(s) of the Consortium/Network (Check all that apply)	Number
	Cardiovascular Disease	Selection list
	Case Management
	Diabetes/Obesity Management
	Elderly Geriatric Care
	Emergency Medical Services (EMS)
	Health Education
	Health Literacy/Translation Services
	Health Promotion/Disease Prevention
	Maternal and Child Health/Women’s Health School Board
	Mental/Behavioral Health
	Network Development Activities
	Nutrition
	Oral Health
	Pharmacy
	Primary Care
	Substance Abuse Treatment
	Telehealth/Telemedicine
	Transportation
	Workforce
	Other – Specify Type:

Table 6: SUSTAINABILITY

Table Instructions: Sustainability:

Please provide the funding/revenue amount, and identify the sources of revenue and sustainability activities. If your grant program has not received any additional funding/revenue, please type zero. Please indicate if the network/consortium will sustain, if the activities of the network consortium will sustain, and if the original need (to create the network/provide services) for the Network/Consortium has been met.

6	Funding/Revenue:	Dollar Amount
	Annual Network revenue
	Additional funding secured to assist in sustaining the project
	Estimated amount of cost-savings due to participation in the network
7	Sources of Revenue: (Check all that apply)	Selection list
	Network/Consortium revenue
	In-Kind Contributions
	Member Fees
	Fundraising
	Contractual Services
	Other – Specify Type:
	Has a sustainability plan been developed using sources of funding besides grants?	Y/N
8	Sustainability Activities: (Check all that apply)	Selection list
	Local, State and Federal Policy Changes
	Media Campaigns
	Consolidation of activities, services and purchases
	Communication Plan Development
	Economic Impact Analysis
	Return on Investment Analysis
	Marketing Plan Development
	Community Engagement Activities
	Business Plan Development
	Incorporation
	Organization Bylaws
	SWOT Analysis
	Other – Specify Activity:
9	Will the Network/Consortium sustain?	Y/N
10	Will any of the activities of the Network/Consortium sustain?	Y/N
11	Has the objectives of the Network/Consortium been met?	Y/N

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