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Site
and Service Inventory
*
1.
Organization Name
(Required.)
*
2.
Site Name
(Required.)
*
3.
Address
(Required.)
Street Address
Suite
City
State
Zip Code
*
4.
Phone
(Required.)
*
5.
Site (Non-Referral) Services Provided
(See Site and Service Audit Definition
sheet
for clarification of terms with an asterisk.)
(Required.)
Primary Care
Dental - Preventive*
Dental - Restorative *
Behavorial Health
Substance Use Disorder
Medication Assisted Treatment (MAT)
OB/GYN
Labor & Delivery
Lactation Education
Doula Services
Family Planning
Mammography*
Cervical Cancer Screening*
Pediatric Services
Developmental Screening*
Diabetes Education
Diabetes DPP/DSME
ER Diversion Agreement w/Hospital*
Podiatry Services
HIV-AIDS Services
Laboratory*
Case Management
Transitional Housing
RX-FQHC is owner/provider
RX-Pharmacy is co-located*
DHS School Based/Linked*
School Located Non-DHS*
Transportation
Administrative
Deaf Services
WIC/Head Start
Nutrition*
Corrections/Jail Services*
Community Health Worker Services
Ophthalmology
Optometry
6.
Other Specialty Care (please explain)
*
7.
Hours Open per Week (check one)
(Required.)
1-10
11-31
32-50
51+
*
8.
Weekends and Evenings (check all that apply)
(Required.)
Open after 6:00 p.m. any weekday
Open Saturday
Open Sunday
*
9.
Section 330 Grant Types for this Site (check all that apply)
(Required.)
Grant: Community Health Center (regular CHC grant, not special population)
Grant: Homeless Grant: Community
Grant: Migrant/Seasonal Farm Worker
Grant: Public Housing
Look-Alike (LAL)
*
10.
Name
(Required.)
*
11.
Title
(Required.)
*
12.
Email
(Required.)
*
13.
Phone
(Required.)
Questions can be directed to Barry Lacy at blacy@iphca.org or (217) 353-1326.
