Community Benefit Survey 2024

Please complete and submit the below survey by December 13, 2024.

Connecticut hospitals do more than care for individuals when they are sick or injured; they promote and protect the health and well-being of their communities.

They work to make their communities healthier through numerous community outreach programs, education efforts, health screenings, and various wellness and prevention activities.  Some of these are reported in annual filings required by the state and federal government, but these reports do not always reflect the breadth and scope of services and benefits provided by Connecticut hospitals. 

CHA is asking hospitals to complete the survey below to provide specific examples of the community health initiatives and benefits they provide in their communities that best highlight this work. These examples will help bolster our collective advocacy work around the impact of community benefits provided by hospitals across the state. Please complete the form below to provide examples of initiatives that address:

  • Access to Health Services
  • Access to Jobs
  • Behavioral Health
  • Food and Nutrition
  • Health Equity
  • Housing
  • Maternal and Child Health
  • Violence Prevention
  • Any Other Issue

If you would like to complete and submit this form as a Word Document, please contact rall@chime.org to request a copy.

To submit photos of any of these initiatives, please email images to rall@chime.org.  CHA may use these photos in advocacy materials and media. 

Community Benefit Survey 2024

Name(Required)
Enter the name of the hospital for which you are completing this survey. Health systems may submit a survey for each acute care hospital.

Access to Health Services

Provide example(s) of programs or initiatives at your hospital that support increasing access to health services (examples: screening, mobile Rx, or mobile primary care). Provide the name of any initiatives with a one-sentence summary and provide any supporting web links if available. If reported on your schedule H, please include the category under which you report.
To add more than one initiative, click the "+" to add additional fields.
Name of Initiative/Program
One Sentence Description
Supporting Links (if any available)
Schedule H Reported Category (If Applicable)
 
If listing an initiative reported in your Schedule H (form 990), please name the category under which it is reported. Indicate on which line you report, or under which of the following categories: Community health improvement services and community benefit operations (line 7e); Health professions education (Line 7f); Subsidized health services (line 7g); Research (line 7h); Cash and in-kind contributions for community benefit (Line 7i); Community-building (Part II, line 10)

Access to Jobs

Provide example(s) of programs or initiatives at your hospital that increase access to jobs and workforce development. Provide the name of any initiatives with a one-sentence summary and provide any supporting web links if available. If reported on your schedule H, please include the category under which you report.
To add more than one initiative, click the "+" to add additional fields.
Name of Initiative/Program
One Sentence Description
Supporting Links (if any available)
Schedule H Reported Category (If Applicable)
 
If listing an initiative reported in your Schedule H (form 990), please name the category under which it is reported. Indicate on which line you report, or under which of the following categories: Community health improvement services and community benefit operations (line 7e); Health professions education (Line 7f); Subsidized health services (line 7g); Research (line 7h); Cash and in-kind contributions for community benefit (Line 7i); Community-building (Part II, line 10)

Behavioral Health

Provide example(s) of programs or initiatives at your hospital that improve behavioral health and remove barriers to care. Provide the name of any initiatives with a one-sentence summary and provide any supporting web links if available. If reported on your schedule H, please include the category under which you report.
To add more than one initiative, click the "+" to add additional fields.
Name of Initiative/Program
One Sentence Description
Supporting Links (if any available)
Schedule H Reported Category (If Applicable)
 
If listing an initiative reported in your Schedule H (form 990), please name the category under which it is reported. Indicate on which line you report, or under which of the following categories: Community health improvement services and community benefit operations (line 7e); Health professions education (Line 7f); Subsidized health services (line 7g); Research (line 7h); Cash and in-kind contributions for community benefit (Line 7i); Community-building (Part II, line 10)

Food and Nutrition

Provide example(s) of programs or initiatives at your hospital that increase access to healthy food and nutrition. Provide the name of any initiatives with a one-sentence summary and provide any supporting web links if available. If reported on your schedule H, please include the category under which you report.
To add more than one initiative, click the "+" to add additional fields.
Name of Initiative/Program
One Sentence Description
Supporting Links (if any available)
Schedule H Reported Category (If Applicable)
 
If listing an initiative reported in your Schedule H (form 990), please name the category under which it is reported. Indicate on which line you report, or under which of the following categories: Community health improvement services and community benefit operations (line 7e); Health professions education (Line 7f); Subsidized health services (line 7g); Research (line 7h); Cash and in-kind contributions for community benefit (Line 7i); Community-building (Part II, line 10)

Health Equity

Provide example(s) of programs or initiatives at your hospital that support increasing health equity. Provide the name of any initiatives with a one-sentence summary and provide any supporting web links if available. If reported on your schedule H, please include the category under which you report.
To add more than one initiative, click the "+" to add additional fields.
Name of Initiative/Program
One Sentence Description
Supporting Links (if any available)
Schedule H Reported Category (If Applicable)
 
If listing an initiative reported in your Schedule H (form 990), please name the category under which it is reported. Indicate on which line you report, or under which of the following categories: Community health improvement services and community benefit operations (line 7e); Health professions education (Line 7f); Subsidized health services (line 7g); Research (line 7h); Cash and in-kind contributions for community benefit (Line 7i); Community-building (Part II, line 10)

Housing

Provide example(s) of programs or initiatives at your hospital that increase access to housing. Provide the name of any initiatives with a one sentence summary and provide any supporting links if available. If reported on your schedule H, please include the category under which you report.
To add more than one initiative, click the "+" to add additional fields.
Name of Initiative/Program
One Sentence Description
Supporting Links (if any available)
Schedule H Reported Category (If Applicable)
 
If listing an initiative reported in your Schedule H (form 990), please name the category under which it is reported. Indicate on which line you report, or under which of the following categories: Community health improvement services and community benefit operations (line 7e); Health professions education (Line 7f); Subsidized health services (line 7g); Research (line 7h); Cash and in-kind contributions for community benefit (Line 7i); Community-building (Part II, line 10)

Maternal and Child Health

Provide example(s) of programs or initiatives at your hospital that support maternal and child health. Provide the name of any initiatives with a one-sentence summary and provide any supporting web links if available. If reported on your schedule H, please include the category under which you report.
To add more than one initiative, click the "+" to add additional fields.
Name of Initiative/Program
One Sentence Description
Supporting Links (if any available)
Schedule H Reported Category (If Applicable)
 
If listing an initiative reported in your Schedule H (form 990), please name the category under which it is reported. Indicate on which line you report, or under which of the following categories: Community health improvement services and community benefit operations (line 7e); Health professions education (Line 7f); Subsidized health services (line 7g); Research (line 7h); Cash and in-kind contributions for community benefit (Line 7i); Community-building (Part II, line 10)

Violence Prevention

Provide example(s) of programs or initiatives at your hospital that support violence prevention. Provide the name of any initiatives with a one-sentence summary and provide any supporting web links if available. If reported on your schedule H, please include the category under which you report.
To add more than one initiative, click the "+" to add additional fields.
Name of Initiative/Program
One Sentence Description
Supporting Links (if any available)
Schedule H Reported Category (If Applicable)
 
If listing an initiative reported in your Schedule H (form 990), please name the category under which it is reported. Indicate on which line you report, or under which of the following categories: Community health improvement services and community benefit operations (line 7e); Health professions education (Line 7f); Subsidized health services (line 7g); Research (line 7h); Cash and in-kind contributions for community benefit (Line 7i); Community-building (Part II, line 10)

Other

Provide additional example(s) of programs or initiatives at your hospital that you wish to highlight that support community health or provide community benefit that do not fit into the above categories. Provide the name of any initiatives with a one-sentence summary and provide any supporting web links if available. If reported on your schedule H, please include the category under which you report.
To add more than one initiative, click the "+" to add additional fields.
Name of Initiative/Program
One Sentence Description
Supporting Links (if any available)
Schedule H Reported Category (If Applicable)
 
If listing an initiative reported in your Schedule H (form 990), please name the category under which it is reported. Indicate on which line you report, or under which of the following categories: Community health improvement services and community benefit operations (line 7e); Health professions education (Line 7f); Subsidized health services (line 7g); Research (line 7h); Cash and in-kind contributions for community benefit (Line 7i); Community-building (Part II, line 10)

To submit photos of any of these initiatives, please email images to rall@chime.org. 

CHA may use these photos in advocacy materials and media.