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:Accounting – CC – 8170Administration – 8250Advanced Orthopedic Specialists – 7851Anesthesia – 6700Anesthesiologists – 6710Biomedical Services – 8060BPN – 8280BRASC – 6506Breast Care Center – 7850Cancer Services Admin – 7310Cape Cardiology Group – 6680Cape Care for Women – 7415Cape Diabetes and Endocrinology – 6820Cape ENT Group – 7417Cape Gastroenterology Specialists – 6865Cape Medical Oncology – 6670Cape Neurology Specialists – 6695Cape Neurosurgical Associates – 7855Cape Pain Management – 7815Cape Physician Associates 4th Floor – 7826Cape Physician Associates Pediatrics 3rd Floor – 7825Cape Pulmonology and Sleep Medicine – 7020Cape Radiation Oncology – 7300Cape Spine and Neurosurgery – 6685Cape Thoracic and Cardiovascular Surgery – 7040Cardiac Rehab Services – 7240Cardiovascular Lab – 7030Case Management – 6521Cat Scanner – 7070Center for Digestive Diseases – 6860Central Supply – 6800Centralized Scheduling – 8180Centralized Telemetry – 7840Clinical Neurophysiology – 7000Communications – 8160Dexter Fitness Plus – 7366Diabetes Education and Management – 7210Electrodiagnostic – 6950Emergency Service – 6850Employee Health – 6840Environmental Services – CC – 8110Facilities Management – 8050Family Birthplace – 6600Financial Planning – 8163Fiscal Services – 8165Fitness Plus – 7295Food Service – CC – 8010Foundation – 8220Gift Shop – 8225Health Home – 7301Health Information Management – 7900Home Health – 7380Hospice – 7420Hospital Billing – 8190Hospitalists – CC – 6830Human Resources – CC – 8150Information Systems – CC – 8210Infusion Center – 7860Inpatient Dialysis – 6770Inpatient Occupational Therapy – 7180Inpatient Physical Therapy – 7200Inpatient Rehabilitation – 6620Inpatient Respiratory Therapy – 7150Intensivist – 6831Laboratory – 6900Laundry and Linen – 8120Legal Services – 8169Level III NICU – 6610Magnetic Resonance Imaging – 7060Marketing – 8130Medical Affairs – 8245Medical Intensive Care – 6550Mission Integration – 8240Mobile Wellness Coach – 7065Neonatology Physicians – 6580Neurosciences – 6512Nuclear Medicine – 7250Nutrition Services – 7370Operating Room – 6650Orthopedics – 6630Outpatient Occupational Therapy – 7190Outpatient Physical Therapy – 7260Outpatient Speech Therapy – 7280Pain Center – 7810Palliative Care – 7425Patient Care Administration – 6400Patient Financial Services – 8175Patient Transport – CC – 8235Performance Improvement – 8020Pharmacy – 7100Pharmacy Poplar Bluff – 7849Physician Recruitment – 8246Physicians Alliance – 6505Population Health – 7299Post Anesthesia Care – 6750Professional Billing – 7340Progressive Care Unit – 6560Psychology Services – 7270Purchasing – 8230Radiology – 7050Registration Center – 7360Rehab Medical – 7838Retail Pharmacy – 7140Same Day Surgery – 6980Security – 7910SF Lab Dexter – 7367SFC Cape KHW PC – 7835SFC Cape KHW UC – 6857SFC Charleston – 7863SFC Clinic Scott City – 7862SFC Dexter – 7365SFC Dexter Physical Therapy – 7155SFC East Prairie – 7864SFC Farmington – 7844SFC JACKSON – 7841SFC PB 2nd Floor – 7858SFC PB 4th Floor – 7842SFC PB Behavioral Health – 7853SFC PB General Surgery – 7780SFC PB Imaging Center – 7363SFC PB Lab – 7843SFC PB Neurology – 7847SFC PB Peds & Endo – 7852SFC PB Urgent Care – 7364SFC Piedmont – 7845SFC Sikeston Lab – 7867SFC Sikeston Non RHC – 7861SFC Sikeston RHC – 7865Sleep Disorders Center – 7160Speech and Hearing – 7230Sterile Processing – CC – 7920Talent Acquistion – 8151Training and Development – 8140Trauma – 6810Ultrasound – 7090Utilization Review – 6835Volunteer Services – CC – 8080Wellness – 7870Wound 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:*NameThis field is for validation purposes and should be left unchanged.
