Dear Community Based Organization (CBO),

The purpose of this survey is to capture current services your organization provide that addresses Social Determinants of Health (SDH) and gauge CBO integration with the New York State VBP program. The goal is also for the State to learn about SDH initiatives to share with the community at large, and to use the information provided to build a public inventory of Tier 1, 2, and 3 CBOs that can be used to facilitate VBP contracting. CBOs will be asked to complete this survey on an annual basis.

* 1. Respondent Information

* 2. Respondent Attestation

* 3. Please briefly describe the type of service(s) your organization provides.

* 4. Please select the SDH category that best aligns with the service(s) your organization currently provides.

* 5. Please identity the county/counties your organization serves.

* 6. How many clients does your organization serve annually?

* 7. Please describe your organization's main source of funding.

* 8. What is the age range of  the population you serve?

* 9. Which of the following CBO Tier is your organization?

* 10. Which of the following Performing Provider Systems (PPS) are located in the region that you serve? Click  HERE for the PPS list, by county.

* 11. Please select the Managed Care Organization(s) that have members in the region that you serve. Click  HERE for the MCO list, by county.