1 Data Form Elements

	Data Element
Entity Overview	Tax ID Number (TIN)
	Provider Type
	Provider Sub-Type
	Business Name
	Doing-Business-As Name - optional
	Street 1+2
	City
	State
	Zip
	Filing Contact Name
	Filing Contact Title
	Filing Contact Phone Number
	Filing Contact Email
Subsidiary Questionnaire	Subsidiaries that are eligible health care providers?
	Acquire or divest subsidiaries during the period of availability of funds?
	Parent reporting on your behalf for General Dist.?
	TIN of parent(s) reporting on your behalf
	Were Targeted Distribution funds transferred to or by a Parent?
	How much Targeted Distribution was transferred to the parent entity?
	TIN of Subsidiary
	Parent reporting on this TIN?
Acquisition/Divestiture information (If Applicable)	TIN of Acquired/Divested Entity
	Acquired or Divested?
	Date of Acquisition or Divestiture
	PRF Received for TIN
	% Ownership
	Did/Do you hold a controlling interest in this entity?
Certification of PRF Payments to Recipient	PRF Funds received > $10k
PRF Interest Earned	Interest earned on Nursing Home Infection Control
	Interest earned on Other PRF
Single Audit	Federal Tax Classification
	Exempt Payee code (optional)
	Exempt from FATCA Reporting Code
	Fiscal Year End Date
	Subjected to Single Audit?
	Were PRF funds included in the audit?
Other Assistance Received during Period of Availability	Treasury, Small Business Administration (SBA) and the CARES Act/Paycheck Protection Program (PPP), Quarterly for Reporting Period
	FEMA CARES Act Funds, Quarterly for Reporting Period
	CARES Act Testing, Quarterly for Reporting Period
	Local, State, and Tribal Government Assistance, Quarterly for Reporting Period
	Business Insurance, Quarterly for Reporting Period
	Other Assistance, Quarterly for Reporting Period
Nursing Home Infection Control Payment Expenditures < $500K (If Applicable)	General and Administrative Costs Attributable to Coronavirus, Quarterly for Reporting Period
	Healthcare Related Expenses Attributable to Coronavirus, Quarterly for Reporting Period
Nursing Home Infection Control Payment Expenditures >= $500K (If Applicable)	Mortgage/Rent, Quarterly for Reporting Period
	Insurance, Quarterly for Reporting Period
	Personnel, Quarterly for Reporting Period
	Fringe Benefits, Quarterly for Reporting Period
	Lease Payments, Quarterly for Reporting Period
	Utilities/Operations, Quarterly for Reporting Period
	Other General and Administrative Expenses, Quarterly for Reporting Period
	Supplies, Quarterly for Reporting Period
	Equipment, Quarterly for Reporting Period
	Information Technology (IT), Quarterly for Reporting Period
	Facilities, Quarterly for Reporting Period
	Other Healthcare Related Expenses, Quarterly for Reporting Period
Other PRF Payment Expenditures < $500K	General and Administrative Costs Attributable to Coronavirus, Quarterly for Reporting Period
	Healthcare Related Expenses Attributable to Coronavirus, Quarterly for Reporting Period
Other PRF Payment Expenditures >= $500K	Mortgage/Rent, Quarterly for Reporting Period
	Insurance, Quarterly for Reporting Period
	Personnel, Quarterly for Reporting Period
	Fringe Benefits, Quarterly for Reporting Period
	Lease Payments, Quarterly for Reporting Period
	Utilities/Operations, Quarterly for Reporting Period
	Other General and Administrative Expenses, Quarterly for Reporting Period
	Supplies, Quarterly for Reporting Period
	Equipment, Quarterly for Reporting Period
	Information Technology (IT), Quarterly for Reporting Period
	Facilities, Quarterly for Reporting Period
	Other Healthcare Related Expenses, Quarterly for Reporting Period
Net Unreimbursed Expenses Atributable to Coronavirus	Net General and Administrative Costs Attributable to Coronavirus, Quarterly for Reporting Period
	Net Healthcare Related Expenses Attributable to Coronavirus, Quarterly for Reporting Period
Type of Lost Revenues Calculation	Reporting on 2019 Actual Revenue, 2020 Budgeted Revenue, or Estimated Lost Revenue?
Lost Revenues Option 1: Revenue Actuals - 2019-2021 (If applicable)	Medicare A + B, Quarterly for Reporting Period
	Medicare C, Quarterly for Reporting Period
	Medicaid/CHIP, Quarterly for Reporting Period
	Commercial Insurance, Quarterly for Reporting Period
	Self-Pay (No Insurance), Quarterly for Reporting Period
	Other, Quarterly for Reporting Period
Lost Revenues Option 2: 2020 Budgeted to Actual (If Applicable)	Medicare A + B, Quarterly for Reporting Period
	Medicare C, Quarterly for Reporting Period
	Medicaid/CHIP, Quarterly for Reporting Period
	Commercial Insurance, Quarterly for Reporting Period
	Self-Pay (No Insurance), Quarterly for Reporting Period
	Other, Quarterly for Reporting Period
	Upload Button for 2020/21 Budget approved prior to March 27th, 2020
	Upload Button for Attestation by CEO, CFO, or Similar Responsibility on accuracy of Budget Submitted
Lost Revenues Option 3: Alternate Reasonable Methodology (If Applicable)	Lost Revenue Estimate (2020/21), Quarterly for Reporting Period
	Upload Narrative Document descibing methodology
	Upload Calculation of Lost Revenues
	Upload additional supporting documentation
Personnel Metrics	Contracted Personnel
	Contracted/Clinical
	Non-clinical
	Full-time Personnel
	Clinical
	Non-clinical
	Part-time Personnel
	Clinical
	Non-clinical
	Hired
	Clinical
	Non-clinical
	Separated
	Clinical
	Non-clinical
	Furloughed Personnel
	Clinical
	Non-clinical
Patient Metrics	Number of Inpatient Admissions
	Number of Outpatient Visits (In person and Telehealth)
	Number of Emergency Department Visits
	Number of Facility Resident Patients (for Long- and Short-term Residential Facilities)
Facility Metrics	Number of Medical/Surgical Beds
	Number of Critical Care Beds
	Number of Other Beds
Survey Questions	(Agree/Disagree) The PRF payments had a significant impact on my overall yearly finances.
	(Yes/No) The PRF payment(s) helped maintain solvency and/or prevent bankruptcy.
	(Check all that apply) PRF payments significantly affected my ability to
	(Yes/No) The PRF payment(s) helped retain staff that otherwise would have been furloughed or terminated.
	(Yes/No) The PRF payment(s) helped re-hire or re-activate staff from furlough.
	(Agree/Disagree) The PRF payment(s) helped to make the changes needed to operate during the pandemic (e.g., by acquiring PPE, creating temporary facilities, providing for virtual visits, etc.).
	(Check all that applies) PRF payment(s) helped facility operations and patient care by allowing our facility to
	(Yes/No) The PRF payment(s) helped care for and/or treat patients with COVID-19 (for applicable treatment facilities).
	Please describe the impact these funds had on the business or patient services. (Optional)
Final Financial Verification	Reporting on RHC COVID-19 Testing complete?
	Certification of accuracy of report