Form rh5

Rural Health Community-Based Grant Program

orhp ndp

Network Development Planning Grant Program

OMB: 0915-0319

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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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File Typeapplication/msword
File TitleNetwork Development Planning Grant Program
AuthorHRSA
Last Modified ByHRSA
File Modified2008-02-15
File Created2008-02-15

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