Form 1 Rural Health Network Development Planning Performance Im

OMB Number: 0915-XXXX

Expiration Date: XX/XX/201X

Rural Health Network Development Planning Program

Performance Improvement and Management System (PIMS) Measures

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 currently 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 average 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 10-29, Rockville, Maryland, 20857.

Table 1: Network Infrastructure

Table Instructions: Please provide information about the network members and network operations. Network members are defined as members who have signed a Memorandum of Understanding or Memorandum of Agreement or have a letter of commitment to participate in the network.

1	Identify the types and number of organizations in the consortium or network for your project:
		Type of Member Organizations in the Consortium/Network			Number
	Non-Profit Organization	Area Health Education Center
		Behavioral/Mental Health Organization
		Community College
		Community Health Center
		Critical Access Hospital
		Faith-based organization
		Free Clinic
		Health Department
		Hospice
		Hospital
		Migrant Health Center
		Private Practice
		Rural Health Clinic
		School District
		Social Services Organization
		University
		Other – Specify type
		TOTAL for non-profit organization			(Automatically calculated by system)
	For-Profit Organization	Critical Access Hospital
		Hospice
		Private Practice
		Rural Health Clinic
		Other – Specify Type
		TOTAL for-profit organization			(Automatically calculated by system)
2	Total number of NEW member organizations that joined the consortium/network during this project period:				Number
3	Indicate the total number of full-member (all members that signed MOU, MOA, or letters of commitment) network meetings conducted during the reported budget year by meeting type:
	Meeting Type				Number
	Meeting conducted face-to-face
	Meeting conducted via teleconference
	Meeting conducted via webinar
	Meeting conducted in a manner not listed above (please specify type)
4	From the beginning of this budget year, assess the following overall Network changes (check one answer for each type of network change):
	Type of Network Change		Increased	No Change	Reduced
	Financial Cost Savings
	Access to Educational Opportunities
	Access to Equipment
	Access to Subject Matter Experts
	Understanding of community health needs
	Other (Please Specify):
5	What area(s) was the network focusing on for this project period? (Check all that apply)
	Cardiovascular disease
	Care coordination
	Care transition
	Children’s health
	Diabetes
	Elderly/Geriatric care
	Emergency Medical Services
	Health information technology
	Health promotion/disease prevention
	Increase access and/or quality of care
	Mental/Behavioral health
	Obesity
	Primary care
	Telehealth/telemedicine
	Workforce
	Other – Specify type

Table 2: Network Collaboration

Table Instructions: Please provide information about collaboration and/or integration among the network members. Refer to the activities listed in the project work plan for this project period.

6	How many activities from the project work plan were initiated by at least two or more network members?	Number
7	How many activities from the project work plan were completed by at least two or more network members?	Number
8	Did the network develop the following (this does not include a needs assessment)?
	Strategic Plan	(Y/N)
	Business Plan	(Y/N)
	Sustainability Plan	(Y/N)
	Other (please specify)
9	What type of Network Planning activities were done during the project period (check all that apply):
	Conduct needs assessment
	Develop a plan (ex: strategic, business)
	Develop network bylaws
	Develop network mission statement
	Develop network governance structure
	Conduct community engagement activities
	Conduct a SWOT analysis
	Other (please specify)

Table 3: Sustainability

Table instructions: Please provide information about the contribution by network members and the network’s sustainability efforts.

10	Annual Program award Please provide the annual program award based on box 12a of your Notice of Award
11	Additional funding secured to assist in sustaining the network Please provide the amount of additional funding that has already been secured during this current project period to sustain the program.
12	Estimated amount of cost savings due to participation in the network during this current project period
13	Sources of Revenue (check all that apply)
	Network revenue
	In-kind contributions
	Member Fees
	Fundraising
	Contractual Services
	Other – specify type
14	How many of the network members have provided the following in-kind services:
	Goods (Ex: equipment, food)	Number
	Services (ex: meeting space)	Number
	Staff support	Number
	Expertise (ex: legal, business, website/marketing development)	Number
	Other (please specify)
15	How many network policies or procedures were created during this budget period:	Number
16	How many network policies or procedures were amended during this budget period:	Number
17	How many network policies or procedures were implemented during this budget period:	Number
18	As a result of being part of the network, how many network member organizations were able to integrate joint policies/procedures within their respective organizations during this budget period?	Number
19	Will the activities of the Network/Consortium continue to operate after the Federal grant funding period?	Y/N

Table 4: Network Assessment

Table instructions: Please provide information regarding the network’s assessment during this project period.

20	Does the network include a process or tool to assess effectiveness of network performance?	Y/N
21	If yes, how is network performance assessed?	open-ended response
22	Does the network include a process or tool to assess effectiveness of network director?	Y/N
23	If yes, how is the network director assessed?	open-ended response
24	Did the network meet its program objectives?	Y/N

Page 15 of 15