The following information and attachments must be included in the community benefits plan filed with the Director of Charitable Trusts:

I. a. General Background Information:

Name and Address of the chief executive officer and board chair:

b. Organizational Structure:

Please attach:

• A copy of the charitable trust's articles of incorporation, constitution, and by-laws, or other instrument of creation.
• A list of the names and addresses of the officers and directors of the organization.
• A brief description of the governance and administrative structure of the health care charitable trust, its parent and subsidiary entities, if any.

II. Community Benefits Contact Person:

• Name and Title:
• Address:
• Telephone Number:

III. Mission Statement:

Statutory reference: RSA 7:32-e I.

The health care charitable trust must provide its most recent mission statement and the date it was adopted. The mission statement must describe the purpose of the health care charitable trust and delineate how the mission statement related to the community benefits reported. The mission statement must be reaffirmed on an annual basis.

Please attach a copy of your mission statement.

IV. a. Program Information

Does your health care charitable trust have a strategic plan that addresses community benefits?

Yes __________ No___________

If yes, please attach a copy of the plan or section(s) of the plan pertaining to community benefits.

b. Program Narrative:

Please provide the following information in a concise statement:

• Who has responsibility for the community benefits programs and activities?
• Who is responsible for their implementation?

If more than one individual is responsible for implementation

(1) please provide a list of the names and the project(s) to which each individual has been assigned or (2) provide the number of individuals assigned to each project.

• How was the health care charitable trust's board involved in development the community benefits program and activities?

V. Definition of Community and Population Served:

Statutory reference: RSA 7:32-d II.

The community may be defined in terms of geographic boundaries, special populations, community groups, demographic characteristics, health status, health resources, healthcare utilization data, etc. A description of the methodology used in identifying and determining the community/population served by the organization must be attached. How does your organization define its community? How was this definition developed? Please be specific.

VI. Community Needs Assessment Information:

Statutory reference: RSA 7:32-f

Following the development of the initial Community Needs Assessment, the assessment must be updated every three years. The charitable trust must consult with members of the public, community organizations, service providers, and local government officials in the trust's service area in order to identify and prioritize the community needs which the health care charitable trust can address directly, or in collaboration with others. The report shall also include the means used to solicit the views of the community served by the trust, identification of community groups, members of the public, and local government officials consulted on the development of the plan, and an evaluation of the plans effectiveness. The Assessment may include, but not be limited to, a description of community demographics, community health indicators, income level of the affected population, specific primary, acute, or chronic health care needs, assessment of the health care charitable trust's capability of responding to identified needs, and the availability of other service providers, both public and private. The Assessment must include a description of the methodology utilized in evaluating and identifying community needs.

• Please describe how community input was solicited and used in developing the community benefits plan.
• Once the needs of the community were identified please describe the process utilized to prioritize the projects chosen.
• Please attach a copy of the most recent Community Needs Assessment

The responses to the following two questions will be used in assessing the overall cost of implementing this law.

• Did the organization hire an outside firm to prepare the Needs Assessment?

Yes___________ No___________

• If the answer is yes, what was the cost of the Needs Assessment?

$_____________

• If the answer is no and the plan was completed internally, how many personnel hours were required to prepare the Needs Assessment? ____________

VII. Collaboration:

Statutory reference: RSA 7:32-f and 7:32-l.

If the community needs assessment is being prepared in collaboration with other health care charitable trusts, please attach a list of the name(s), address(es), and telephone number(s) of the collaborating organization(s) and the relationship, if any, between these organizations. One health care charitable trust should be selected as the contact for the collaborative.

Please Note: One copy of the community needs assessment should be filed for the collaborative. Participating charitable trusts should make reference to this collaborative assessment in preparing their community benefits plans.

What was the beginning date of the fiscal year used for this collaboration?
____________________________

VIII. Community Benefit Plan:

Statutory reference: RSA 7:32-e.

The document filed must include a listing of community benefits or benefit activities planned by the health care charitable trust. Health care charitable trusts working in collaboration with other organizations are required to provide individual information pursuant to RSA 7:32-l. For each community benefit activity, the following information must be included:

• A description of the benefit or benefit activity and how the activity will further the mission of the organization and the objectives of the community needs assessment.
• The need to be addressed and the target/affected population for the benefit
• The goal(s) to be accomplished
• Objectives to be achieved within the target dates and the methodology utilized to measure and assess outcomes.
• If the plan was prepared in collaboration with other health care charitable trusts, please complete Section VII.

IX. Inventory and Valuation of All Community Benefits:

Statutory reference: RSA 7:32-d III and 7:32-e IV and V

Describe in detail the cost of the community benefits planned by the health care charitable trust and the methodology for estimating the cost. The plan shall include an estimate of the cost of each activity expected to be undertaken or supported in the ensuing year and a report on the unreimbursed cost of each activity undertaken in the preceding year. For each quantifiable benefit, the trust should provide an economic valuation which identifies the unreimbursed cost to the trust of providing the benefit and the method for calculating that cost. Nonquantifiable benefits should be identified separately and described in narrative form.

X. Annual Assessment of Community Benefits Activities:

Statutory reference: RSA 7:32-e IV

The plan shall include a report on the community benefit activities undertaken by the trust in the preceding year and information describing the results or outcomes of the trust's community benefit activities. The report shall also include the means used to solicit the views of the community served by the trust, identification of community groups, members of the public, and local government officials consulted on the development of the plan, and an evaluation of the plans effectiveness.

Please be sure the assessment section is included in the plan.

THE COMPLETED COMMUNITY BENEFITS PLAN MUST BE FILED WITH THE ATTORNEY GENERAL WITHIN 90 DAYS OF THE BEGINNING OF THE FISCAL YEAR. FAILURE TO FILE THE PLAN MAY RESULT IN THE IMPOSITION OF CIVIL PENALTIES OF $1,000 PLUS ATTORNEYS FEES AND COSTS (RSA 7:32-g III) EXTENSIONS MAY BE REQUESTED BY FILING THE APPLICATION FOR EXTENSION OF TIME TO FILE COMMUNITY BENEFITS PLAN FORM WITH THE ATTORNEY GENERAL.

NOTE: A copy of RSA 7:32-c - l will be included with the form mailed to health care charitable trusts.