Community Benefit Inventory for Social Accountability (CBISA) Program Form GeneralProgram 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. A1. Community Health EducationA2. Community Based Clinical ServicesA3. Health Care Support ServicesA4. Social and Environmental Improvement ActivitiesB1. Physicians / Medical StudentsB2. Nurses / Nursing StudentsB3. Other Health Professions EducationB4. Scholarships / Funding for Professional EducationC1. Emergency and Trauma ServicesC2. Neonatal Intensive CareC3. Hospital Outpatient ServicesC4. Burn UnitC5. Women's and Children's ServicesC6. Renal Dialysis ServicesC7. Subsidized Continuing CareC8. Behavioral Health ServicesC9. Palliative CareD1. Clinical ResearchD2. Community Health ResearchE1. Cash DonationsE2. GrantsE3. In-Kind DonationsF1. Physical Improvements / HousingF2. Economic DevelopmentF3. Community SupportF4. Environmental ImprovementsF5. Leadership Development / Training for Community LeadersF6. Coalition BuildingF7. Advocacy for Community Health ImprovementF8. Workforce DevelopmentG1. Assigned StaffG2. Community Health Needs / Health Assets AssessmentG3. Other ResourcesObjectivesObjectives:*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 / FormatFormat:* 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 OccurrencesBrief Description of Activity:*Please include location detailsSponsoring Department*Select a Department:3rd Floor ACC – 6500Accounting – 8170ACO – 7299Administration – 8250Advanced Orthopedic Specialists – 7851Ambulance – 7080Anesthesia – 6700Anesthesiology – 6710Audit – 8168AWL Family Healthcare System – 7836Bio-Medical Services – 8060Black River Management – 8255BRASC – 6506Business Development – 8135Call Center – 6845Cancer Services Administration – 7310Cap Labor EMR Pre-Implementation – 6640Cape Cardiology Group – 6680Cape Care for Women – 7415Cape Cerebrovascular & Endovascular Neurosurgery – 6690Cape Diabetes & Endocrinology – 6820Cape ENT Group – 7417Cape Gastroenterology Specialists – 6865Cape Gynecologic Oncology – 6790Cape Medical Group – 7837Cape Medical Oncology – 6670Cape Neurology Specialists – 6695Cape Neurosurgical Associates – 7855Cape Pain Management – 7815Cape Pediatric Group – 7846Cape Perinatology Services – 6590Cape Physician Associates – 7825Cape Primary Care – 7835Cape Pulmonology & Sleep Medicine – 7020Cape Radiation Oncology – 7300Cape Spine and Neurosurgery – 6685Cape Thoracic & Cardiovascular Surgery – 7040Cardiac Intensive Care Unit – 6540Cardiac Rehab Services – 7240Cardiovascular Lab – 7030Case Management – 6521Cat Scanner – 7070Center for Digestive Diseases – 6860Central Supply – 6800Centralized Scheduling – 8180Centralized Telemetry – 7840CGO Prov Based – 9020Charleston Family Care – 7833Chest Pain & Stroke Centers – 7025Clinical Neurophysiology – 7000CMO Prov Based – 9010Communications – 8160Continuing Care Clinic – 7412Copper Top Pharmacy PB – 7857COVID 19 Unit – 6515COVID Infusion Center – 6516CTVS Prov Based – 9040Customer Service – 7390Cyberknife – 7330Deli Plus – 8017Dexter Fitness Plus – 7366Diabetes Education & Management – 7210Disaster Management – 6817Durable Medical Equipment – 7165Electrodiagnostic – 6950Emergency Room – 6850Employee Health – 6840Endovascular Lab – 6990Entrance 2 Convenient Care – 6856Entrance Management – 6813Environmental Services – 8110EPIC – 7890ERC – 8301ERC Northeast – 8303ERC Southwest – 8302Evaluation Unit – 6780Facilities Management – 8050Family Birthplace – 6600Farmington Physician Associates – 7844Ferguson Medical Group – 7861Ferguson Medical Group CH – 7863Ferguson Medical Group EP – 7864Ferguson Medical Group Lab – 7867Ferguson Medical Group SC – 7862Ferguson Medical Group SI – 7865Financial Planning – 8163Fiscal Services – 8165Fitness Center – 7290Fitness Plus – 7295Float Orderlies – 8200Food Service – 8010Foundation – 8220Friends Cafe – 8015General Medical – 6502Healing Arts Infusion Center – 7790Healing Arts Lab – 6920Healing Arts Urgent Care – 6859Health & Wellness Cat Scan – 6960Health Home – 7301Health Information Management – 7900Home Health – 7380Home Infusion Therapy – 7130Hospice – 7420Hospital Billing – 8190Hospitalists – 6830HR Misc Budget Dollars – 8155HRSA 93.110 – 8248HRSA 93.912 – 8247HRSA Outreach Grant – 6975Human Resources – 8150Immediate Convenient Care – 6857Immediate Convenient Care – Jackson – 7839Immediate Convenient Care Perryville – 6858Infection Prevention – 7880Information Systems – 8210Infusion Center – 7860Infusion Center Dexter – 7355Inpatient Dialysis – 6770Inpatient Occupational Therapy – 7180Inpatient Physical Therapy – 7200Inpatient Rehabilitation – 6620Inpatient Respiratory Therapy – 7150Inspire Boutique – 8225Intensivist – 6831IV Therapy – 7120Jackson Family Care – 7832Kids Plus – 7297Knee, Hip and Shoulder Clinic – 6985Kneibert Clinic – 7848Kneibert Lab – 6912Kneibert Pharmacy – 7849Laboratory – 6900Laundry and Linen – 8120Learning and Development – 8140Legal Services – 8169Level III NICU – 6610LTACH – 7500Magnetic Resonance Imaging – 7060Marketing – 8130Medical Affairs – 8245Medical Director – 7410Medical Intensive Care – 6550Medical Library – 7800Medical Office Building – 7400Mission Integration – 8240Neonatology – 6580Neurosciences – 6512Nuclear Medicine – 7250Nursery – 6660Nutrition Service – 7370NWM Behavioral Health – 7853NWM Pharmacy – 7854Occupational Medicine – 6855OP Children's Center – 6520Open MRI – 6970Operating Room – 6650Orthopaedic-Surgical – 6630Outpatient Occupational Therapy – 7190Outpatient Physical Therapy – 7260Outpatient Rehab Services – 7170Outpatient Speech Therapy – 7280Pain Center – 7810Palliative Care – 7425Patient Care Administration – 6400Patient Financial Services – 8175Patient Transport – 8235PB Condo – 6705Performance Improvement – 8020Performance Plus – 7292Pet Scanner – 7010Pharmacy – 7100Physical Therapy Dexter – 7155Physician Recruitment – 8246Physicians Alliance – 6505Physicians Park General Surgery – 7780Physicians Park Primary Care – 7842Piedmont Physician Associates – 7845Plant Operations – 8040Poplar Bluff Neurology Specialists – 7847Poplar Bluff Occupational Therapy – 7856Poplar Bluff Pediatrics – 7852Post Anesthesia Unit – 6750PPPC – Lab – 7843PPPC Audiology – 7834Print Shop – 8100Professional Billing – 7340Progressive Care Unit – 6560Psychology Services – 7270Purchasing & Receiving – 8230Quality Improvement – 7411Radiation Therapy – 7320Radiology – 7050Registration Center – 7360Rehab Administration Services – 7220Rehab Medical – 7838Reimbursed Salaries – 8030Retail Pharmacy – 7140Saint Francis Breast Care Center – 7850Saint Francis Clinic Jackson – 7841Saint Francis Outpatient Center – 7365Saint Francis Outpatient Center – Imaging – 7363Saint Francis Outpatient Center PB – 7364Same Day Surgery – 6980Security – 7910SFC PB 2nd – 7858Sikeston Imaging Center – 7866Sikeston Radiation Oncology – 7350Sleep Disorders Center – 7160Social Services – 8090SPD Reprocess – 7930Specialty Clinic – 7830Speech and Hearing – 7230Starr Training – 8300Sterile Processing – 7920STF Regional Lab – 6910Surgical – 6510Surgical Trauma Intensive Care – 6530The Healthy Weigh – 7298Tobacco Cessation – 7872Transfer Center – 6812Trauma – 6810Trauma Surgery Physicians – 6815Ultrasound – 7090Utilization Review – 6835Vein Center – 6760Volunteers – 8080Weight Loss Solutions – 6720Wellness – 7870Worksite Tobacco – 7873Wound Care – 7820Number of People Served:* ExpensesSalaries:*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 Select files Max. file size: 15 MB. Other Notes / Comments:Your Name:* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Your Phone Number:*Your Email Address: Your Job Title at Saint Francis Healthcare System:*
