Hospital Closing Survey

This "survey" is being used to capture any data available regarding rural hospital closure. The survey is two parts. Part 1 asks four basic questions to capture basic information about the closed hospital. Part 2 Is optional and asks 7 questions which will inform efforts to understand and address issues which contribute to hospital closures Thanks for helping us track this important issue.

Question Title

* Demographic Information

Hospital Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Question Title

* Please provide information on the date of the hospital closure, to the best of your knowledge.

Actual date. The hospital is closed and the date is confirmed.

Actual/estimated date. The hospital is closed but I am uncertain of the specific official date of closure.

Expected date. The hospital has not closed yet. The expected date listed below is estimated.

Please list an actual OR actual/estimate OR expected date of closure.

Question Title

* Type of hospital

Unsure

Critical access hospital - not necessary provider

Critical access hospital - necessary provider

Medicare Dependent Hospital (MDH)

Prospective Payment System Hospital (PPS)

Other (please specify)

Question Title

* Did this hospital receive Disproportionate Share Hosptial payments?

Yes

Unsure

Question Title

* Your name and contact information. Please note this information will only be used if you reply yes to agree to be contacted for more information.

Name:

Company:

State:

Email Address:

Phone Number:

Question Title

* Are you interested in answering additional questions about the hospital closure which may help inform and shape policy to address hospital closure.

Yes