Schedule H (Form 990) - Hospitals - 2015 Page 4
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Schedule H (Form 990) 2015
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 letter of facility reporting group
Line number of hospital facility, or line numbers of hospital
facilities in a facility reporting group (from Part V, Section A):
Yes
No
Community Health Needs Assessment
1
Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the
current tax year or the immediately preceding tax year?.
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1
2
Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or
the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C . .
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3
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 12 .
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3
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 significant 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)
4
Indicate the tax year the hospital facility last conducted a CHNA: 20
5
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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5
6 a 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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6a
b Was the hospital facility's CHNA conducted with one or more organizations other than hospital facilities? If “Yes,”
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6b
list the other organizations in Section C
7
Did the hospital facility make its CHNA report widely available to the public?
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7
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
Made a paper copy available for public inspection without charge at the hospital facility
d
Other (describe in Section C)
8
Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If “No,” skip to line 11
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9
Indicate the tax year the hospital facility last adopted an implementation strategy: 20
10
Is the hospital facility's most recently adopted implementation strategy posted on a website? .
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10
a If “Yes,” (list url):
b If “No,” is the hospital facility's most recently adopted implementation strategy attached to this return? .
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10b
11
Describe in Section C how the hospital facility is addressing the significant needs identified in its most
recently conducted CHNA and any such needs that are not being addressed together with the reasons why
such needs are not being addressed.
12 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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12a
b If “Yes” to line 12a, did the organization file Form 4720 to report the section 4959 excise tax? .
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12b
c If “Yes” to line 12b, 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) 2015
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