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Yes
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No
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Community Health Needs Assessment
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1
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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
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No |
2
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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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2
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No |
3
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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 12......................
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3
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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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4
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Indicate the tax year the hospital facility last conducted a CHNA: 20
16
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5
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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 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
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Yes |
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6 a
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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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6a
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No |
b
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Was the hospital facility’s CHNA conducted with one or more organizations other than hospital
facilities?” If “Yes,” list the other organizations in Section C.
............................
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6b
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No |
7
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Did the hospital facility make its CHNA report widely available to the public?..............
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7
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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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8
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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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8
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Yes |
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9
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Indicate the tax year the hospital facility last adopted an implementation strategy: 20
16
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10
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Is the hospital facility's most recently adopted implementation strategy posted on a website?.........
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10
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Yes |
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a
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If "Yes" (list url):
WWW.FHN.ORG
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b
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If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return?
......
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10b
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11
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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.
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12a
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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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12a
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No |
b
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If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........
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12b
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c
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If "Yes" on line 12b, 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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