2019 Houston Methodist Grant Program: Quarterly Reports

Please complete this report form and submit at the conclusion of each quarter. If your organization is receiving support from more than one grant, you will need to submit this questionnaire twice. All quarterly reports are due by the 15th of April, July, October, January.

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* 1. General Information

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* 2. Which Houston Methodist Grant are you reporting on?

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* 3. Which Quarter Are Your Reporting On?

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* 4. Based on the end of the Quarter in question, what is the total number of unduplicated patients who have been served across your entire organization and the number of patient visits?

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* 5. Based on the end of the Quarter in question, please indicate the total number of unduplicated patients who have been served with the specific Houston Methodist grant funds awarded. If your award is helping to provide salary support for a provider, please report the number of unduplicated patients/clients seen by that provider.

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* 6. How much of the Houston Methodist grant award has been utilized so far?

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* 7. Have there been any significant changes in your organization or the funded project since the grant was awarded. (i.e. executive leadership changes, staff, facilities, etc)?

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* 8. What progress have you made in achieving the results you described in your grant proposal during this period? What evidence do you have to demonstrate your success?

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* 9. Non-Grant Question: Community Scholars Program: If your organization is host to a specialty via the Community Scholars Program, please let us know how many patients you have referred to our Scholars thus far and any additional information you would like to make us aware of.

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* 10. Non-Grant Question: Network of Care Program: If your organization is part of the Community Network of Care initiative, please let us know how many patients you believe Houston Methodist has referred to your facility and/or provide any information you would like to make us aware of in connection to this program.

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