Form 5 Network Development Planning

Rural Health Community-Based Grant Program

Network Planning PIMS Measures--FINAL

Network Development Planning Grant Program

OMB: 0915-0319

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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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