Community Benefit Inventory for Social Accountability (CBISA) Program Form

Email
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General
Program Date:*
Month
Day
Year
Title of Program*
Category of Program*
Choose the one best fit / primary focus. Please review the reference guide for assistance / examples.
Objectives
Objectives:*
Is This Program Duplicated in the Community?*
- Yes
- No
Does This Program Address an Unmet Community Need?*
- Yes
- No
Is This a Collaborative Effort?*
- Yes
- No
Who Are the Partners Collaborating with You, and What Are Their Respective Roles?*
Setting / Format
Format:*
- Clinic
- Events / Meetings
- Health Fairs / Screenings
- Newsletter
- Seminars
- Speaker’s Bureau
- TV/Radio
- Other
Specify "Other" Format:*
Target Audience(s)
Primary County for Program:*
Are There Any Special Needs Populations That Benefit?:*
- Persons with Disabilities
- Racial, Cultural and Ethnic Minorities
- Uninsured / Underinsured
- Other
Specify "Other" Special Needs Populations:*
Age(s) of Targeted Audience:*
Select multiple if applicable
- Infants
- Children
- Teens
- Adults
- Seniors
Occurrences
Brief Description of Activity:*
Please include location details
Sponsoring Department*
Number of People Served:*
Expenses
Salaries:*
Please select the pay grade(s) of associated individuals.
* Please note that these are paid hours for colleagues only. *
- Executive
- Physician
- Nurse
- Director
- Manager
- Assistant Manager
- Technical
- Clerical
- Respiratory Therapist
- Nurse Practitioner
- Physical Therapist
- Speech Pathologist
- Fitness Specialist
- Group Exercise Instructor
- Pharmacist
- Medical Assistant
- Physician Assistant
- Radiology Tech
- Social Worker
- Bio Med
- Maintenance
- Occupational Therapist
- Marketing
- Surgical Tech
- Registered Dietician
- Certified Athletic Trainer
- MT/MLT Tech
- Nurse Assistant
- Massage Therapist
- Paramedic
- Coding Specialist
- CRNA
- Other
Executive Details:*
Please enter the name(s) and number of hours for associated executives, one per line.
* Please note that these are paid hours for colleagues only. *
Physician Details:*
Please enter the name(s) and number of hours for associated physicians, one per line.
* Please note that these are paid hours for colleagues only. *
Nurse Details:*
Please enter the name(s) and number of hours for associated nurses, one per line.
* Please note that these are paid hours for colleagues only. *
Director Details:
Please enter the name(s) and number of hours for associated directors, one per line.
* Please note that these are paid hours for colleagues only. *
Manager Details:*
Please enter the name(s) and number of hours for associated managers, one per line.
* Please note that these are paid hours for colleagues only. *
Assistant Manager Details:*
Please enter the name(s) and number of hours for associated assistant managers, one per line.
* Please note that these are paid hours for colleagues only. *
Technical Personnel Details:*
Please enter the name(s) and number of hours for associated technical personnel, one per line.
* Please note that these are paid hours for colleagues only. *
Clerical Personnel Details:*
Please enter the name(s) and number of hours for associated clerical personnel, one per line.
* Please note that these are paid hours for colleagues only. *
Respiratory Therapist Details:*
Please enter the name(s) and number of hours for associated respiratory therapists, one per line.
* Please note that these are paid hours for colleagues only. *
Nurse Practitioner Details:*
Please enter the name(s) and number of hours for associated nurse practitioners, one per line.
* Please note that these are paid hours for colleagues only. *
Physical Therapist Details*
Please enter the name(s) and number of hours for associated physical therapists, one per line.
* Please note that these are paid hours for colleagues only. *
Speech Pathologist Details:*
Please enter the name(s) and number of hours for associated speech pathologists, one per line.
* Please note that these are paid hours for colleagues only. *
Fitness Specialist Details:*
Please enter the name(s) and number of hours for associated fitness specialists, one per line.
* Please note that these are paid hours for colleagues only. *
Group Exercise Instructor Details:*
Please enter the name(s) and number of hours for associated group exercise instructors, one per line.
* Please note that these are paid hours for colleagues only. *
Pharmacist Details:*
Please enter the name(s) and number of hours for associated pharmacists, one per line.
* Please note that these are paid hours for colleagues only. *
Medical Assistant Details:*
Please enter the name(s) and number of hours for associated medial assistants, one per line.
* Please note that these are paid hours for colleagues only. *
Physician Assistant Details:*
Please enter the name(s) and number of hours for associated physician assistants, one per line.
* Please note that these are paid hours for colleagues only. *
Radiology Tech Details:*
Please enter the name(s) and number of hours for associated radiology techs, one per line.
* Please note that these are paid hours for colleagues only. *
Social Worker Details:*
Please enter the name(s) and number of hours for associated social workers, one per line.
* Please note that these are paid hours for colleagues only. *
Bio Med Personnel Details:*
Please enter the name(s) and number of hours for associated bio med personnel, one per line.
* Please note that these are paid hours for colleagues only. *
Maintenance Personnel Details:*
Please enter the name(s) and number of hours for associated maintenance personnel, one per line.
* Please note that these are paid hours for colleagues only. *
Occupational Therapist Details:*
Please enter the name(s) and number of hours for associated occupational therapists, one per line.
* Please note that these are paid hours for colleagues only. *
Marketing Personnel Details:*
Please enter the name(s) and number of hours for associated Marketing personnel, one per line.
* Please note that these are paid hours for colleagues only. *
Surgical Tech Details:*
Please enter the name(s) and number of hours for associated surgical tech, one per line.
* Please note that these are paid hours for colleagues only. *
Registered Dietician Details:*
Please enter the name(s) and number of hours for associated registered dietician, one per line.
* Please note that these are paid hours for colleagues only. *
Certified Athletic Trainer Details:*
Please enter the name(s) and number of hours for associated certified athletic trainer, one per line.
* Please note that these are paid hours for colleagues only. *
MT / MLT Tech Details:*
Please enter the name(s) and number of hours for associated Mt / MLT tech, one per line.
* Please note that these are paid hours for colleagues only. *
Nurse Assistant Details:*
Please enter the name(s) and number of hours for associated nurse assistant, one per line.
* Please note that these are paid hours for colleagues only. *
Massage Therapist Details:*
Please enter the name(s) and number of hours for associated massage therapist, one per line.
* Please note that these are paid hours for colleagues only. *
Paramedic Details:*
Please enter the name(s) and number of hours for associated paramedic, one per line.
* Please note that these are paid hours for colleagues only. *
Coding Specialist Details:*
Please enter the name(s) and number of hours for associated coding specialist, one per line.
* Please note that these are paid hours for colleagues only. *
CRNA Details:*
Please enter the name(s) and number of hours for associated CRNA, one per line.
* Please note that these are paid hours for colleagues only. *
Other Colleague Details:*
Please enter the name(s) and number of hours for associated colleague, one per line.
* Please note that these are paid hours for colleagues only. *
Other Expenses:*
Please select the expense type, then enter the amount and vendor information for each.
- Purchased Services
- Supplies
- Other Direct Expenses
- Indirect Expenses
- None
Purchased Services Expense Amount:*
Purchased Services Expense Description:*
Supplies Expense Amount:*
Supplies Expense Description:*
Other Direct Expense Amount:*
Other Direct Expense Description:*
Indirect Expense Amount:*
Indirect Expense Description:*
Offsetting Revenue:*
This is reporting of money earned from the activity for Saint Francis. Please choose the type of revenue, then enter the amount and description related to each.
- Foundation / Fundraising
- Fees Collected
- Other (Voluntary) Contributions
- Grants / Support Collected
Foundation / Fundraising Amount:*
Foundation / Fundraising Description:*
Amount of Fees Collected:*
Description of Fee(s):*
Other (Voluntary) Contributions Amount:*
Other (Voluntary) Contributions Description:*
Grants / Support Revenue Amount:*
Grants / Support Revenue Source:*
Please Attach Any Supporting Documents:
Drop files here or

Max. file size: 32 MB.
Other Notes / Comments:
Your Name:*
Title First Last
Your Phone Number:*
Your Email Address:
Your Job Title at Saint Francis Healthcare System:*

Community Benefit Inventory for Social Accountability (CBISA) Program Form

General

Objectives

Setting / Format

Target Audience(s)

Occurrences

Expenses