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Yes
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No
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Community Health Needs Assessment (Lines 1 through 8c are optional for tax years begining on or before March 23, 2012)
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1
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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
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Yes |
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If "Yes," indicate what the CHNA report describes (check all that apply):
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a
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b
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c
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d
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e
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f
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g
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h
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i
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j
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2
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Indicate the tax year the hospital facility last conducted a CHNA: 20
13
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3
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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 Part VI 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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3
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Yes |
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4
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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 Part VI..................................
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4
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No |
5
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Did the hospital facility make its CHNA report widely available to the public?..............
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5
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Yes |
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If "Yes," indicate how the CHNA report was made widely available (check all that apply):
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a
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b
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c
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d
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6
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If the hospital facility addressed needs identified in its most recently conducted CHNA, indicate how (check all that apply as of the end of the tax year):
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a
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b
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c
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d
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e
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f
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g
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h
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i
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7
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Did the hospital facility address all of the needs identified in its most recently conducted CHNA? If "No," explain in Part VI which needs it has not addressed and the reasons why it has not addressed such needs...........
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7
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Yes |
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8a
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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
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No |
b
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If "Yes" to line 8a, did the organization file Form 4720 to report the section 4959 excise tax?
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8b
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c
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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?
$
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