Site and Service Inventory

Question Title

1. Organization Name (Required.)

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2. Site Name (Required.)

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3. Address (Required.)

Street Address

Suite

City

State

Zip Code

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4. Phone (Required.)

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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

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6. Other Specialty Care (please explain)

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7. Hours Open per Week (check one) (Required.)

1-10

11-31

32-50

51+

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8. Weekends and Evenings (check all that apply)

Open after 6:00 p.m. any weekday

Open Saturday

Open Sunday

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9. Section 330 Grant Types for this Site (check all that apply) (Required.)

Grant: Community Health Center (regular CHC grant, not special population)

Grant: 330(h) Homeless Population

Grant: 330(g) Migrant/Seasonal Worker

Grant: 330(i) Residents of Public Housing

Look-Alike (LAL)

Question Title

10. Name (Required.)

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11. Title (Required.)

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12. Email (Required.)

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13. Phone (Required.)

Questions can be directed to Barry Lacy at blacy@iphca.org or (217) 353-1326.

Site and Service Inventory

Question Title

* 1. Organization Name (Required.)

Question Title

* 2. Site Name (Required.)

Question Title

* 3. Address (Required.)

Question Title

* 4. Phone (Required.)

Question Title

* 5. Site (Non-Referral) Services Provided (See Site and Service Audit Definition sheet for clarification of terms with an asterisk.) (Required.)

Question Title

* 6. Other Specialty Care (please explain)

Question Title

* 7. Hours Open per Week (check one) (Required.)

Question Title

* 8. Weekends and Evenings (check all that apply)

Question Title

* 9. Section 330 Grant Types for this Site (check all that apply) (Required.)

Question Title

* 10. Name (Required.)

Question Title

* 11. Title (Required.)

Question Title

* 12. Email (Required.)

Question Title

* 13. Phone (Required.)

1. Organization Name (Required.)

2. Site Name (Required.)

3. Address (Required.)

4. Phone (Required.)

5. Site (Non-Referral) Services Provided
(See Site and Service Audit Definition sheet for clarification of terms with an asterisk.) (Required.)

6. Other Specialty Care (please explain)

7. Hours Open per Week (check one) (Required.)

8. Weekends and Evenings (check all that apply)

9. Section 330 Grant Types for this Site (check all that apply) (Required.)

10. Name (Required.)

11. Title (Required.)

12. Email (Required.)

13. Phone (Required.)