Community Benefit Inventory for Social Accountability (Cbisa4)

COMMUNITY BENEFIT INVENTORY FOR SOCIAL ACCOUNTABILITY (CBISA4)

Community Benefit Report

Title of Activity:______

Description:______

______

______

Sponsoring Dept #:______Contact Person:______

Dept. Name:______Phone:______

Community Service Categories (Check all that fit the primary focus)

A. NONBILLED SERVICESD. RESEARCH (ALL)

 A1. Community Education & Outreach

 A2. ScreeningsE. CASH & INKIND DONATIONS

 A3. Support Groups E1. Cash Donations

 A4. Counseling E2. In-Kind Donations

 A5. Self-help

 A6. ImmunizationsF. COMMUNITY BUILDING ACTIVITIES

 A7. Clinics F1. Physical Improvement

 A8. Patient Education F2. Economic Development

 A9. (User Defined)______ F3. Support System Enhancements

 F4. Environmental Improvements

B. MEDICAL EDUCATION F5. Leadership Development & Skills Training

 B1. Physicians, Medical Students F6. (User Defined)______

 B2. Scholarships/Funding for Profession Education

 B3. Nurses

 B4. Technicians

 B5. Other Health Professionals

 B6. Other

 B7. (User Defined)______

C. SUBSIDIZED HEALTH SERVICES

C1. Emergency & Trauma Services

C2. Neonatal Intensive Care

 C3. Free-standing Community Clinic

 C4. Collaborative Efforts in Preventive Medicine

 C5. Obstetrical/Newborn Care

 C6. Renal Dialysis Services

 C7. Hospice/Home Care

 C8. Other

 C9. (User Defined)______

Page 2

Community Benefit Report

Objectives:______

______

Is this a collaborative effort? If so, who are the other participants?

______

______

______

______

 Is this activity duplicated in the community?

Does this activity address an unmet community need?

Outcomes (general):______

______

______

______

______

ACTIVITY SETTING / LOCATION:ACTIVITY FORMAT:

 InpatientSeminars

 OutpatientHealth Fairs/Screenings

 In FacilityEvents/Meetings

 Community (School, community center, mall)Speaker's Bureau

 WorkplaceNewsletter

 HomeTV/Radio

 Other______Clinic

Other ______

SPECIAL NEEDS POPULATION

 1. Persons with disabilities

 2. Racial, cultural and ethnic minorities

 3. Uninsured/underinsured

 Other ______

AGE OF TARGETED AUDIENCE:GENDER:TARGETED FOR:

 infants adults male  low income

 children seniors female  broader community

 teens all ages both

CBISA 4Page 3

Healthy Community 2010

PUT A CHECK MARK BY EACH CATEGORY THAT THIS ACTIVITY ADDRESSES:

Group IPromote Healthy Behaviors

1.Promote Physical Activity & Fitness

2.Promote Nutrition

3.Reduce Tobacco Use

4.Reduce Use of Alcohol & Other Drugs

5. ______

6.______

Group IIPromote Healthy and Safe Communities

1. Promote Community-based Education

2. Improve Environmental Health

3. Improve Food and Drug Safety

4. Improve Oral Health

5. Improve Occupational Safety and Health

6. Prevent Injuries

7. Prevent Violence and Abuse

8. ______

9.______

Group IIIImprove Systems for Personal and Public Health

1.Promote Family Planning

2.Improve Access to Quality Preventive Care

3.Improve Access to Quality Primary Care

4.Improve Access to Quality Emergency Care

5.Improve Access to Quality Long-term Care

6.Improve Maternal, Infant and Child Health

7.Improve Medical Product Safety

8. Improve Public Health Infrastructure

9. Improve Health Communication

10.

11.

CBISA 4Page 4

Healthy Community 2010 (cont.)

PUT A CHECK MARK BY EACH HEALTH ISSUE THAT THIS ACTIVITY ADDRESSES:

Group IV

GROUP A – Software Screen
CHRONIC DISEASES
CANCER 1. Alzheimers
 1. Breast Cancer 2. Arthritis
 2. Cervical Cancer 3. Chronic Back
 3. Colorectal Cancer 4. Diabetes
 4. Lung Cancer 5. Multiple Sclerosis
 5. Prostate Cancer 6. Muscular Dystrophy
 6. Skin Cancer 7. Osteoporosis
 7.______ 8.______
 8. ______ 9.______
CARDIOVASCULARINFECTIOUS DISEASES
 1. Blood Pressure 1. Hepatitis
 2. Cardiac Rehab 2. HIV
 3. Cholesterol 3. Influenza
 4. Stroke 4. Measles/Rubella
 5.______ 5. Sexually Transmitted Diseases
 6.______ 6.______
 7.______
GROUP B - Software Screen
MENTAL HEALTHSENSORY NEEDS
 1. Mental Health and Mental Disorders 1. Hearing
 2. Anxiety/Panic Disorders 2. Speech
 3. Compulsive Behavior Disorders 3. Vision
 4. Depression 4.______
 5. Grief 5.______
 6. Stress
 7. Suicide
 8. Violent/Abusive BehaviorOTHER
 9.______ 1. Burns
 10.______ 2. Eating Disorders
 3. Falls
PULMONARY 4. Head/Spinal Cord
 1. Asthma 5. Oral Health
 2. Pneumonia 6. Poison Control
 3. Tuberculosis 7. Prescription Drug Misuse
 4.______ 8.______
 5.______ 9.______

CBISA 4

MONTHLY REPORT

Date: _____/_____/_____ Title of Activity:______

Brief description:______

Sponsoring Dept. #:_____ Total Persons Served: ______Total Staff Hrs (Paid): ______

Sub Dept# (if any):______Total Volunteer Hrs ______

EXPENSES

Salaries
Total Paid Staff Hours X Pay Rate $ ______
(You may leave blank if pay rate is not known.)

Purchased Services$______

Supplies$______
Other Direct Expenses$______
Indirect Expenses$______

FUNDING & OFFSETTING REVENUE

Foundation/Fundraising/Grant/Support$______
Source of Grant:______
Total Fees Received from Participants$______
Other (voluntary contributions, etc.)$______
Other Notes / Comments (if any):______
______
______

Form completed by Name:______Phone:______

E-Mail:______Fax:______

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