RHC 2012 Data Survey

The Colorado Rural Health Center and ClinicNET are working to complile this information to help inform our work as we communicate with legislators, stakeholders, and potential funders of the vital role and services rural clinics and other safety-net clinics provide in our state. Thank you for taking a few minutes to complete this brief survey.

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1. Clinic Name (Required.)

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2. Mailing Address (Required.)

Line 1

Line 2 (Optional)

City

State

Zip

County

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3. Physical Address (if different from Mailing Address)

Line 1

Line 2 (Optional)

City

State

Zip

County

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4. Contact Information (Required.)

Clinic Phone Number

Clinic Fax Number

Web Address

Primary Clinic Contact Name

Primary Clinic Contact Title

Primary Clinic Contact Email

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5. Year Founded

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6. Type of Clinic (Required.)

Provider-Based Federally Certified Rural Health Clinic

Provider-Based Rural Health Clinic (not federally certified)

Independent Federally Certified Rural Health Clinic

Independent Rural Health Clinic (not federally certified)

Who owns your clinic? (i.e. name of hospital or physician)

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7. Number of staff (Required.)

Full-time administrative

Part-time administrative

Full-time clinical

Part-time clinical

Other

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* 1. Clinic Name (Required.)

Question Title

* 2. Mailing Address (Required.)

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* 3. Physical Address (if different from Mailing Address)

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* 4. Contact Information (Required.)

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* 5. Year Founded

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* 6. Type of Clinic (Required.)

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* 7. Number of staff (Required.)

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* 8. If you selected "Other" above, please explain

1. Clinic Name (Required.)

2. Mailing Address (Required.)

3. Physical Address (if different from Mailing Address)

4. Contact Information (Required.)

5. Year Founded

6. Type of Clinic (Required.)

7. Number of staff (Required.)

8. If you selected "Other" above, please explain