Network Name: Grant Project Name (if different than network name): State: List your long-term HRSA grant goals (i.e., the long-term outcomes of your grant project) and your Network strategic goals (the strategies or short- to mid-term outcome of your grant project): Your Long-Term Grant Goals for Network Your Short- to Mid-Term Network Strategic Planning Grant Goals 1. 2. 3. B. What Should We Look Like? Network Board Development The Network’s membership structure is: CAHs Behavioral Health Providers Community Health Centers Small Hospitals Schools/School Districts Community-Based Medium Hospitals Public Health Departments Organizations Large Hospitals Free Clinics Other: Rural Health Clinics Physician-Owned Clinics Why does this structure make for your Network? Is there any reason to consider different organizations or members? Who specifically would you add? The Board Agreement to Serve (Board Member Job Description) has been created and published. Yes No Will not use an Agreement Will be developed at a later date
Network Name: Grant Project Name (if different than network name): State: List your long-term HRSA grant goals (i.e., the long-term outcomes of your grant project) and your Network strategic goals (the strategies or short- to mid-term outcome of your grant project): Your Long-Term Grant Goals for Network Planning Grant Your Short- to Mid-Term Network Strategic Goals 1. 2. 3. B. What Should We Look Like? Network Board Development The Network’s membership structure is: CAHs Small Hospitals Medium Hospitals Large Hospitals Rural Health Clinics Behavioral Health Providers Schools/School Districts Public Health Departments Free Clinics Physician-Owned Clinics Community Health Centers Community-Based Organizations Other: Why does this structure make for your Network? Is there any reason to consider different organizations or members? Who specifically would you add? The Board Agreement to Serve (Board Member Job Description) has been created and published. Yes No Will not use an Agreement Will be developed at a later date
Network%20Self-Assessment%20Tool_Nov%202015_0.docx