Entering Your Example of an Effort Leveraging the Social Determinants of Health

To submit a case or example, please respond to the questions below. To learn more about Community Health Centers Leveraging the Social Determinants of Health, visit the project overview page.

Your Contact Information

Full Name: *

Your Position or Title:

Organization (Health Center): *

Organization Website:

Phone number and/or email address: *

Additional Contacts, if applicable:

What is the name of the effort (activity, project, program, or intervention)?: *

What is the background experience that inspired this effort?:

Please describe the effort(s) to leverage the social determinants of health: *

Are any websites associated with this effort? Please provide the URL(s):

Who is the audience? Who are the recipients?:

What are the objectives or goals of this effort?:

Where does the activity occur? Please give full address of site(s):

Staffing - Staff and Volunteers

For the next four questions we would like you to describe your employed and volunteer workforce involved in this effort. Please use full-time equivalents (FTEs) to estimate how much time your workforce contributed to this effort. For example:

employed administrator: 2 people, total 0.75 FTE

employed clinician: 4 people, total 2.25 FTE

employed support staff: 6 people, total 3.5 FTE

volunteer clinician: 1 people, American Red Cross, total 0.5 FTE

volunteer support staff: 10 people, AmeriCorps, total 9.5 FTE

List employed administrative staff (number of people, total FTE):

List employed clinicians (number of people, total FTE):

List employed support staff (number of people, total FTE):

List volunteers (number of people; source [AmeriCorp, American Red Cross, etc]; total FTE):

How is this effort funded? List all sources:

If the effort is a collaboration, what is the role of the health care provider organization and who are the principal partners?:

Select all that apply

The clinic in this effort is a:

FQHC

FQHC Look-Alike

Free Clinic

Indian Health Services Clinic

Other (please specify):

How is the impact of the effort monitored and evaluated?:

Please report the data results here:

If the effort is ongoing, how is it sustained?:

Has this effort been written about in the scientific literature, newspapers, or on the web?:

Is there anything else you would like to say about this effort?:

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