Community Health Needs Assessment Template

This template for reporting community health needs assessments (CHNAs) was developed by the Catholic Health Association of the United States as a guide for standardized reporting. It was adapted from the final rules issued by the Internal Revenue Service on December 2014 that implement CHNA requirements for tax-exempt hospitals. Please note that this template is being provided for educational purposes and does not represent legal or tax advice.

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Hospital Name:

Tax Years Covered:

Community Served by the Hospital

A definition of the community served by the hospital and description of how the community was determined.

Community Health Needs Assessment Process

A description of the process and methods used to conduct the assessment.

A description of the data and other information used in the assessment.

The methods of collecting and analyzing this data and information. In the case of data obtained from external source material, the report may cite the source material rather than describe the method of collecting the data.

Any parties with whom the hospital collaborated in conducting the CHNA.

Any parties with whom the hospital contracted for assistance in conducting the CHNA.

Community Input

A description of how the hospital took into account input from persons who represent the broad interests of the community it serves. The description must include:

Summary, in general terms, of any input provided by such persons, including how and over what time period such input was provided (for example, whether through meetings, focus groups, interviews, surveys, written comments and between what approximate dates).The names of any organizations providing input, and a summary of the nature and extent of their input.

A description of the medically underserved, low-income, and minority populations being represented by organizations or individuals that provide input. The regulations note that the report does not need to name or otherwise identify any specific individual providing input on the CHNA.

In the event a hospital solicits, but cannot obtain, input from a source described in IRS regulations the hospital‘s CHNA report must describe the hospital’s efforts to solicit input from such source.

Prioritized Significant Community Health Needs

A prioritized description of the significant health needs of the community identified through the CHNA.

A description of the process and criteria used in identifying certain health needs as significant and in prioritizing those significant health needs.

Potentially Available Resources

A description of resources potentially available to address the significant health needs identified through the CHNA.

Evaluation of Impact

An evaluation of the impact of any actions that were taken, since the hospital finished conducting its immediately preceding CHNA, to address the significant health needs identified in the hospital’s prior CHNAs.

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Date adopted by authorized body of hospital