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Program Submission Form
Please complete this form to submit your program for review. You may be contacted by America's Essential Hospitals staff for additional details or clarifications.
Program Submission Form
Contact Information
Hospital
*
Program Contact Name
*
Program contact Email Address
*
Can this email address be used to allow others to contact you about your program?
Yes, other essential hospitals can contact me directly about my program.
No, I prefer to be contacted by America's Essential Hospitals if someone is interested in my program.
Program Information
Social Determinant(s) Addressed by Program (select up to 3)
2
3
4
5
6
Climate Vulnerability
Community Infrastructure
Education
Employment & Income
Family & Social Support
Food Insecurity
Health Behaviors
Health Literacy
Housing Instability
Interpersonal Violence
Legal Needs
Social Needs Screening
Structural Racism
Transportation
Utility Needs
Use Ctrl to select up to three
Primary Social Determinant Addressed by Program
*
Community Infrastructure
Education
Employment & Income
Family & Social Support
Food Insecurity
Health Behaviors
Health Literacy
Housing Instability
Interpersonal Violence
Legal Needs
Social Needs Screening
Transportation
Utility Needs
Structural Racism
Please select one option
Program Name
*
Is this Program Currently Active?
Yes
No
Target Populations
Adults
Children/Adolescents
Disabled
Families
Men
Minorities
Older Adults
Women
Use Ctrl to select multiple
Partner(s)
e.g. community partners, funders, internal departments
Partner(s) Category
Education
External Community Organization
External Funders
External Health Care
Government
Small Business
Use Ctrl to select multiple
Program Setting(s)
Community
Hospital
Use Ctrl to select multiple
In 2-4 sentences, please describe how this program got started as well as the program goals
In 3-4 sentences, please describe the scope of the program (e.g., populations served, operational structure) and what resources are allocated from the hospital, or partners, to operate the program (e.g., funding, staff, IT)
In 2-3 sentences, please describe how this program collaborates with other hospital departments, and/or external community partners
In 2-3 sentences, please describe the outcomes or outputs of the program, as well as any results to-date
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