Schedule H (Form 990) - Hospitals - 2013 Page 4
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Schedule H (Form 990) 2013
Page
Part V
Facility Information (continued)
Section B. Facility Policies and Practices
(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Name of hospital facility or facility reporting group
If reporting on Part V, Section B for a single hospital facility only: line number of
hospital facility (from Schedule H, Part V, Section A)
Yes
No
Community Health Needs Assessment
)
(Lines 1 through 8c are optional for tax years beginning on or before March 23, 2012
1
During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a
community health needs assessment (CHNA)? If “No,” skip to line 9. .
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1
If “Yes,” indicate what the CHNA report describes (check all that apply):
a
A definition of the community served by the hospital facility
b
Demographics of the community
Existing health care facilities and resources within the community that are available to respond to the
c
health needs of the community
d
How data was obtained
e
The health needs of the community
f
Primary and chronic disease needs and other health issues of uninsured persons, low-income persons,
and minority groups
g
The process for identifying and prioritizing community health needs and services to meet the
community health needs
h
The process for consulting with persons representing the community's interests
i
Information gaps that limit the hospital facility's ability to assess the community's health needs
j
Other (describe in Section C)
2
Indicate the tax year the hospital facility last conducted a CHNA:
20
3
In conducting its most recent CHNA, did the hospital facility take into account input from persons who
represent the broad interests of the community served by the hospital facility, including those with special
knowledge of or expertise in public health? If “Yes,” describe in Section C how the hospital facility took into
account input from persons who represent the community, and identify the persons the hospital facility
consulted .
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Was the hospital facility's CHNA conducted with one or more other hospital facilities? If "Yes," list the other
hospital facilities in Section C .
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Did the hospital facility make its CHNA report widely available to the public?
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If “Yes,” indicate how the CHNA report was made widely available (check all that apply):
a
Hospital facility's website (list url):
b
Other website (list url):
c
Available upon request from the hospital facility
d
Other (describe in Section C)
If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check
6
all that apply as of the end of the tax year):
a
Adoption of an implementation strategy that addresses each of the community health needs identified
through the CHNA
b
Execution of the implementation strategy
c
Participation in the development of a community-wide plan
d
Participation in the execution of a community-wide plan
e
Inclusion of a community benefit section in operational plans
f
Adoption of a budget for provision of services that address the needs identified in the CHNA
g
Prioritization of health needs in its community
h
Prioritization of services that the hospital facility will undertake to meet health needs in its community
i
Other (describe in Section C)
7
Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If “No,”
explain in Section C which needs it has not addressed and the reasons why it has not addressed such needs
7
8 a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a
CHNA as required by section 501(r)(3)? .
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8a
b If “Yes” to line 8a, did the organization file Form 4720 to report the section 4959 excise tax?
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8b
c If “Yes” to line 8b, what is the total amount of section 4959 excise tax the organization reported on Form
4720 for all of its hospital facilities?
$
Schedule H (Form 990) 2013
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