Community Benefit Inventory for Social Accountability (CBISA) Program Form

General

Title of Program*

Category of Program*

Choose the one best fit / primary focus. Please review the reference guide for assistance / examples.

Objectives

Objectives:*

Community Need(s) Being Addressed:*

How Need was Determined (Assessed):*

(a) Improve Access
(b) Enhance Community Health
(c) Advance Knowledge
(d) Relieve/Reduce Burden

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

Setting / Location*

Specify "Other" Setting(s) / Location(s):*

Format:*

Specify "Other" Format:*

Target Audience(s)

County:*

Gender(s)*

Select multiple if applicable

Male
Female

Special Needs Populations:*

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

Occurrences

If you have multiple occurrences for the SAME ACTIVITY in the same quarter, you may use a single form. Please list all dates and give the total amounts for each expense/revenue category.

Date(s):*

Title of Activity:*

Brief Description of Activity:*

Setting(s) / Location(s):*

Sponsoring Department:*

Department Number:*

Number of People Served:*

Expenses

Salaries:*

Please select the pay grade(s), then enter the number of hours and the name(s) of associated individuals.

Executive Hours:*

Name(s) of Executive(s):*

Physician Hours:*

Name(s) of Physician(s):*

Nurse Hours:*

Name(s) of Nurse(s):*

Director / Manager Hours:*

Name(s) of Director(s) / Manager(s):*

Assistant Manager Hours:*

Name(s) of Assistant Manager(s):*

Professional Hours:*

Name(s) of Professional(s):*

Technical Hours:*

Name(s) of Technical Personnel:*

Clerical Hours:*

Name(s) of Clerical Personnel:*

Service Hours:*

Name(s) of Service Personnel:*

Other Expenses:*

Please select the expense type, then enter the amount and vendor information for each.

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. 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

Other Notes / Comments:

Your Name:*

Title First Last

Your Phone Number:*

Your Email Address:

Your Job Title at Saint Francis Healthcare System:*