EmailMeForm
2023 NAFC Member Data & Standards Report
Annually, as a
membership requirement
of the NAFC, member organizations must provide previous-year data in order to remain a member in good standing.
This data is critical to help the NAFC identify funding opportunities, educational/training resources, and in-kind contributions. It helps to enhance the NAFC's ability to educate policymakers, the press, and the public about the important work you provide to your communities.
Please note:
In January, organizations will receive weekly reminders; February 1-10, you will receive two weekly reminders; and on February 13-21, organizations will receive daily reminders. Once your organization has completed the data form, the NAFC will remove you from the reminders list.
NAFC Member Organizations must complete this data survey by
February 21, 2023
in order to remain a member in good standing.
You will receive an emailed copy of your submitted answers when you click on "Submit" at the end of the form.
To view a copy of the NAFC Standards document
, please visit:
https://nafcclinics.org/wp-content/uploads/2022/01/2022-NAFC-Quality-Standards-Final.pdf
To view a sample toolkit with examples of the standards in the Standards Document,
please visit:
https://nafcclinics.org/wp-content/uploads/2022/01/2022-NAFC-Quality-Standards-TOOLKIT-FINAL-sm.pdf
*IMPORTANT NOTE:
If you click on "Save & Resume" at the bottom of this form, a screen will appear with a unique link for you to come back to your saved form. If you lose your unique link to log back in, or if it doesn't work for any reason - please email Melanie Castillo at melanie@nafcclinics.org.
Please do not start this form again.
*PLEASE NOTE:
Any question with an asterisk (*) next to it is required. Any questions without the asterisk are optional.
Questions about this form may be emailed to
melanie@nafcclinics.org
Contact Information
Please fill out the following section with the most up-to-date information for your organization.
Organization Name (as it should be listed on the public NAFC website)
*
Federal EIN (Tax ID) for your organization OR your parent organization:
*
Organization Main Physical Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
County for main physical address:
What congressional district is your organization physically located? For example, 8th district of Virginia or VA-8
Look up your district: https://www.house.gov/representatives/find-your-representative
Organization's Mailing Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Organization Phone (for patient and volunteer inquiries, to be listed on the public NAFC website)
*
###
-
###
-
####
Direct Contact Phone (for NAFC staff to reach you in case of emergency)
*
###
-
###
-
####
Contacts
The following contacts will automatically receive official NAFC communications.
Primary Contact Name
*
First
Last
Primary Contact Title
*
Primary Contact Email Address
*
Please select all listservs for which this contact should be added:
*
General Listserv
Providers Listserv
Epic Users Listserv
athenahealth Users Listserv
Practice Fusion Users Listserv
None
Secondary Contact Name
*
First
Last
Secondary Contact Title
*
Secondary Contact Email Address
*
Please select all listservs for which this contact should be added:
*
General Listserv
Providers Listserv
Epic Users Listserv
athenahealth Users Listserv
Practice Fusion Users Listserv
None
Medical or Clinical Director Name
*
First
Last
Medical or Clinical Director Email Address
*
Please select all listservs for which this contact should be added:
*
General Listserv
Providers Listserv
Epic Users Listserv
athenahealth Users Listserv
Practice Fusion Users Listserv
None
Website Address (type N/A if you don't have one)
*
Organization Twitter URL (type N/A if you don't have one)
*
Organization Instagram URL (type N/A if you don't have one)
*
Organization Facebook URL (type N/A if you don't have one)
*
Organization YouTube URL (type N/A if you don't have one)
*
Does your organization have multiple sites?
*
No
Yes, (once this is clicked, you will be able to provide us with addresses for your additional sites)
Address for Additional Site #1 (optional)
Street Address
City
State / Province / Region
Postal / Zip Code
County for Additional Site #1 (optional)
Congressional District for Additional Site #1 (optional)
Address for Additional Site #2 (optional)
Street Address
City
State / Province / Region
Postal / Zip Code
County for Additional Site #2 (optional)
Congressional District for Additional Site #2 (optional)
Address for Additional Site #3 (optional)
Street Address
City
State / Province / Region
Postal / Zip Code
County for Additional Site #3 (optional)
Congressional District for Additional Site #3 (optional)
Address for Additional Site #4 (optional)
Street Address
City
State / Province / Region
Postal / Zip Code
County for Additional Site #4 (optional)
Congressional District for Additional Site #4 (optional)
Address for Additional Site #5 (optional)
Street Address
City
State / Province / Region
Postal / Zip Code
County for Additional Site #5 (optional)
Congressional District for Additional Site #5 (optional)
Address for Additional Site #6 (optional)
Street Address
City
State / Province / Region
Postal / Zip Code
County for Additional Site #6 (optional)
Congressional District for Additional Site #6 (optional)
Address for Additional Site #7 (optional)
Street Address
City
State / Province / Region
Postal / Zip Code
County for Additional Site #7 (optional)
Congressional District for Additional Site #7 (optional)
Address for Additional Site #8 (optional)
Street Address
City
State / Province / Region
Postal / Zip Code
County for Additional Site #8 (optional)
Congressional District for Additional Site #8 (optional)
Organization Structure
My organization is considered a...
Free Clinic:
The nonprofit clinic provides all goods and services at no charge directly to uninsured and/or underserved patients. "Services" include medical, dental, mental health/behavioral health, and/or medications. Clinic may request or suggest donations. Clinic does not bill any third-party payers, including Medicaid, Medicare, or commercial insurers. Clinic may be bricks-and-mortar clinic or mobile unit.
Charitable Clinic:
The nonprofit clinic provides goods and/or services for a fee directly to uninsured and/or underserved patients. "Services" include medical, dental, mental health/behavioral health, and/or medications. Clinic may use a flat fee or sliding fee scale. Clinic may bill patients but does not bill third-party payers, including Medicaid, Medicare, or commercial insurers. Clinic may be bricks-and-mortar clinic or mobile unit.
Hybrid Clinic:
The clinic is a free clinic or charitable clinic as defined above, except that it also bills one or more third-party payers, such as Medicaid, Medicare, or commercial insurers. Clinic has not been designated as a Federally-Qualified Health Center (FQHC), FQHC Look-Alike, or Rural Health Clinic.
Student-Run Clinic:
A free or charitable clinic that is mainly run by students. Clinic may be housed within a university or school.
Stand-Alone Free/Charitable Pharmacy:
The licensed pharmacy dispenses free or low-cost medications directly to uninsured and/or underserved patients.
Federally Qualified Health Center (FQHC):
Federally funded nonprofit health centers or clinics that serve medically underserved areas and populations. Federally qualified health centers provide primary care services regardless of your ability to pay. Services are provided on a sliding scale fee based on your ability to pay.
HRSA-designated Rural Health Clinic:
Clinics in underserved rural areas that have received a special certification by the Centers for Medicare & Medicaid Services (CMS) and receive enhanced reimbursement rates for providing Medicare and Medicaid services.
My organization is considered a...:
*
Free Clinic
Charitable Clinic
Hybrid Clinic
Student Run Clinic
Stand-Alone Free/Charitable Pharmacy
Federally Qualified Health Center (FQHC)
FQHC Look-Alike
HRSA-designated Rural Health Clinic
Is your organization faith-based?
*
Yes
No
Previous Year's Cash Operating Expenses for clinic/pharmacy only, not parent organization: (Please do not include in-kind contributions)
*
Organization's Year of Incorporation
*
Does your organization have a Board subcommittee/taskforce/committee looking at diversity and inclusion?
*
Yes
No
No, but this is something we want to have
Does your organization have a quality improvement subcommittee/taskforce/committee?
*
Yes
No
No, but this is something we want to have
If your state has a state association for Free/Charitable Clinics, is your organization a member?
*
Yes
No
My state does not have a state association
In what kind of area is your organization located?
*
Rural
Urban
Suburban
In what kind of area(s) do your patients generally reside? (please select all that apply)
*
Rural
Urban
Suburban
Does your clinic exclusively serve any of the following:
*
Entire state
Specific Zip Codes (please list)
Specific Counties (please list)
No patient location requirement
Other
If you answered "Specific Zip Codes" above, please list the zip codes separated by commas.
If you answered "Specific Counties" above, please list the county names separated by commas.
Do you have an income requirement for your patients? Please select which statement below applies:
*
No income requirement
Up to 100% of Federal Poverty Level (FPL)
Up to 200% of Federal Poverty Level (FPL)
Up to 300% of Federal Poverty Level (FPL)
Up to 400% of Federal Poverty Level (FPL)
Other
How do you screen your patients for Medicaid or other insurance eligibility?
*
We do not screen for insurance eligibility
Patient self-attests they have no insurance
Check insurance status through online database
Check insurance status by contacting Medicaid office
Patient must show Medicaid denial letter
Other
Patient Fees and Medicaid/Medicare Reimbursement: Recognizing that fees/reimbursement may vary depending on the patient, which types of fees or reimbursements does your clinic/pharmacy use?
Free/No Cost to Patient
Recommended Donation (Suggested Donation)
Accepts Donations
Flat Fee
Sliding Scale Fee
Medicaid/ Medicare/State CHIP
Other Payer
Primary Care
Laboratory
Prescription Medication
Dental
Mental Health
If you selected having recommended donations (suggested donation), flat fees, or sliding fee scale - please indicate the amounts below.
Recommended Donation (suggested donation)
Flat Fee
Sliding Fee Scale
None (type "0" or "none" here)
Primary Care
Laboratory
Prescription Medication
Dental
Mental Health
Organization Services
Please click on the "Yes (on-site)" or "Yes (off-site)" columns for all services your organization provides at this time:
Yes (ON-site)
Yes (OFF-site)
AADE Diabetes Education Program
Access to Food
Acupuncture
Acute Care
ADA Diabetes Self-Management Education
Blood Pressure Home Monitoring
Case Management
Child Care
Chiropractic
Cooking Classes
Dental
Dermatology
Dietitian/Nutrition
Discounted Pharmacy Cards
Domestic Violence Counseling/Assistance
Employment Assistance
Family Planning
Fill Rx's on-site
Financial Assistance
Gift Cards for Patients
Health Education
HIV Treatment
Labs
Legal Assistance
Mammogram Referrals
Maternal Health
Medication Therapy Management (MTM)
Mental Health
National Diabetes Prevention Program
Neurology
OBGYN
On-Site Mammography
Orthopedic
Other Diabetes Education
Pediatric
Physical Therapy
Podiatry
Prenatal Care
Primary Care
Referrals
Screening - Breast Cancer
Screening - Cervical Cancer
Screening - Colorectal Cancer
Screening - Lung Cancer
Screening - Oral Cancer
Screening - Other Cancers
Screening - Skin Cancer
Social Services
Specialty Care
STI/STD Testing
Substance Abuse Treatment
Surgery
Telehealth (may include non-clinical services)
Telemedicine (remote clinical services)
Tobacco Cessation Counseling
Tobacco Cessation Referral
Tobacco Cessation Treatment
Translation Services
Transportation Assistance
Vaccinations - Adult
Vaccinations - Child
Vaccinations - COVID-19
Vaccinations - Flu
Vision
Women's Health
Write Rx's for filling off-site
Do you have an on-site pharmacy/dispensary?
*
Yes
No
Do you use a Pharmacy Management Software? If so, which one?
No
No, but we would like to have one
Yes:
If you do not have a pharmacy or dispensary on-site, where do your patients fill their prescriptions?
*
Costco
CostPlus
CVS
Kroger
Publix
Rx Outreach
Target
Walgreens
Walmart
Nowhere, we have a pharmacy/dispensary on-site
Other
Does your organization help process PAP (patient assistance program) forms for your patients on-site?
*
Yes
No
Does your organization have a "mobile unit" that provides care?
*
Yes
No
Do you use an Electronic Health Record/Electronic Medical Record System? If so, which one?
*
No
Yes - athenahealth
Yes - DataNet Solutions
Yes - Epic
Yes - eClinical Works
Yes - MD Rhythm
Yes - Practice Fusion
Yes - Other:
Languages in which we provide healthcare services and/or outreach (e.g., through multilingual staff, interpreters)
Yes
American Sign Language (ASL)
Chinese (Szechuan, Mandarin, Cantonese, etc.)
Eastern European Languages (Russian, Georgian, Ukranian, etc.)
French
Languages of the Middle East (Arabic, Persian, Dari, Pashto, Aramaic, Yiddish, etc.)
Languages of the Indian subcontinent (Hindu, Punjab, Urdu, Bengali, Telugu, Tamil, etc.)
Spanish
Non-Spanish Indigenous languages spoken in Central/South America (Mam, Quechua, etc.)
Languages of Africa (Swahili, Amharic/Somali, Bantu, Sudanese, Yoruba, etc.)
Languages of southeast Asia (Vietnamese, Cambodian, etc.)
Other(s)
None, only English
Languages in which our services are needed but we do not yet have the capacity to provide:
Yes
American Sign Language (ASL)
Chinese (Szechuan, Mandarin, Cantonese, etc.)
Eastern European Languages (Russian, Georgian, Ukranian, etc.)
French
Languages of the Middle East (Arabic, Persian, Dari, Pashto, Aramaic, Yiddish, etc.)
Languages of the Indian subcontinent (Hindu, Punjab, Urdu, Bengali, Telugu, Tamil, etc.)
Spanish
Non-Spanish Indigenous languages spoken in Central/South America (Mam, Quechua, etc.)
Languages of Africa (Swahili, Amharic/Somali, Bantu, Sudanese, Yoruba, etc.)
Languages of southeast Asia (Vietnamese, Cambodian, etc.)
Other(s)
We are NOT in need of any other languages
Please select the top two (2) barriers in providing services in needed languages:
*
Technology
Staffing
Cost
Volunteers
Broadband/Internet Access
Other
Please select the top ten (10) medications that your organization prescribes to your patients. (REQUIRED)
Actos
Advair Diskus
Albuterol
Amitriptyline
Amlodipine 10mg
Atorvastatin 40mg
Basaglar
Bupropion
Buspirone
Carvedilol 25mg
Clopidogrel
Combivent
Cymbalta
Donepezil
Fenofibrate
Flovent HFA
Fluoxetine
Glipizide 10mg
Humalog
Hydrochlorothiazide 25mg
Invokana
Janumet 50/1000mg
Januvia 100mg
Lisinopril 20mg
Lithium
Metformin 1000mg
Metoprolol
Paroxetine
Pradaxa
Prednisone
Risperdal
Rosuvastatin
Singulair
Spiriva
Symbicort
Trulicity
Ventolin 90 mcg
None
In the next 18 months, will your organization be purchasing or requesting any products/services from the following companies? Please select all that apply: (REQUIRED)
Adhearx
Amazon
Americares
athenahealth
Atlantic Medical Solutions
Benco Dental
Bionime
Capstone Health Network
Cardinal Health
Caremessage
Citrix
Cyracom
Direct Relief
Dispensary of Hope
DocResponse
Eko
Eli Lilly
Globus Relief
Gold Star International
GrantStation
Heart to Heart International
Henry Schein Dental
Henry Schein Medical
Independence Medical
Johnson & Johnson
JVK Scientific
Language Line Solutions
Maven Project
McKesson
MD Rhythm
Mutual of America
Network for Good
Nonprofit Leadership Lab
Novo Nordisk
Office Depot
Patterson Dental
Phillips Healthcare
Practice Fusion
Project HOPE
Qwark
Rx Outreach
Safco Dental
SafeNetRx
Sanofi
Siemens Healthcare
Staples
Stericycle
SW Healthcare Solutions
TCI Software
The Pharmacy Connection
Tri State Distribution
Trividia Health
Updox
Volunteer Scheduler Pro
Walmart
None
Social Determinants of Health
Does your organization have a policy or system in place to screen all patients for non-clinical social needs (social determinants of health)?
*
Yes, and we have examples to share
Yes, we are working on this
We need help with this
No
If your clinic screens for social determinants of health, which ones do you screen?
We screen for this
Food Insecurity
Housing
Education
Employment
Finance
Literacy
Transportation
Child Care
Personal Safety
Utilities
Ability to afford prescribed medications
Does your organization have a policy or system in place to refer all patients for non-clinical social needs (social determinants of health)?
*
Yes, and we have examples to share
Yes, we are working on this
We need help with this
No
Does your organization have a policy or system in place to follow-up with all patients for non-medical social needs (social determinants of health)?
*
Yes, and we have examples to share
Yes, we are working on this
We need help with this
No
Please select all screening tools that are used in your organization:
*
AAFP Social Needs Screening Tool
Accountable Health Communities Health-Related Social Needs Screening Tool (AHC-HRSN)
Adult ACE Screener
Generalized Anxiety Disorder (GAD-2)
Generalized Anxiety Disorder (GAD-7)
HealthBegins Upstream Risks Screening Tool
Hunger Vital SignTM (Food Insecurity)
Kaiser Permanente's Your Current Life Situation (YCLS)
Patient Health Questionnaire (PHQ-9)
Patient Health Questionnaire (PHQ-2)
Pediatric ACEs and Related Life-events Screener (PEARLS)
Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE)
None of the above
Other
Please select the top ten (10) needs for your organization. (REQUIRED QUESTION)
Choose Ten (10)
Access to imaging/radiology services
Access to laboratory services
Access to specialty care consults for providers
Access to specialty care for patients
Affordable Medication
Board Development Training
Capital Funding
CEU Opportunities
Clinical Staff
Clinical Volunteers
Community Health Workers
Contraceptives
Cryptocurrency Donation Training
Dehumidifiers
Diagnostic Instruments/Equipment
Disease Management Funding
Diversity and Inclusion Training
Ductless Heat Pumps
Energy Efficient Doors
Energy Efficient Light Bulbs
Energy Efficient Refrigerators/Freezers
Energy Efficient Windows
Flu Vaccines
Fundraising
Generators
Gift Cards for Patients
Grantwriting
Heat Pump Water Heaters
Incentive/Reward Funding for Staff/Volunteers
Infectious Disease Training
Inventory Management System
Laptops/Computers/Tablets
Learning collaboratives for specific health topics or services (e.g., dental, mental health)
Learning collaboratives with faith-based clinics
Learning collaboratives with similar budget clinics
Learning collaboratives with similar patient size clinics
Marketing and Public Relations Resources
Mental Health Professional Development for Clinicians
Mental Health Self-Care for Staff/Volunteers
Mentorship to expand hours/capacity
Mobile Unit Funding
Non-Clinical Staff
Non-Clinical Volunteers
Operations Funding
Personal Protective Equipment
Pharmacy Software
Programmatic Funding
Room Air Purifiers
Self-Care Funding
Solar Panels
Solar Water Heaters
Storm Windows
Technical Assistance
Technology Funding
Telehealth Diagnostic Equipment
Telehealth/Telemedicine Products
Translation/Interpretation Services
Transportation Vouchers
Vaccine Refrigerators
Value of Service Methods
Virtual learning opportunities
Website Development
Please indicate if your organization participated with a state or local coalition that focused on any of the following in 2022. Coalitions may also be described as committees, task forces, or other groups that bring together partners across multiple organizations and sectors. For each of the topics below, please indicate if your organization 1) received government funding, 2) received private funding, 3) participated in a statewide coalition, or 4) participated on a local coalition. If you participated in a coalition that addressed multiple topics, please check all of the topics addressed.
Received Government (federal/state or local) Funding
Received Private Funding (NAFC/United Way/etc.)
Participated on Statewide Coalition
Participated on Local Coalition
Maternal and child health, including reproductive health
Breast and Cervical Cancer Screenings)
Chronic disease prevention (hypertension, diabetes, obesity, asthma, arthritis etc.)
Violence and injury prevention (including car seat checks, QPR training, sexual abuse, domestic abuse, etc.)
Mental health (including depression, anxiety, talk therapy, etc.)
Substance abuse (including overdose prevention, naloxone, etc.)
Oral health
Health equity, health disparities or social determinants of health
COVID-19 testing, education, vaccination
Rural Health
Ryan White HIV/AIDS Program
Tobacco prevention and control
Did your organization receive any funding or participate on a coalition that is specific to any of the following populations:
Rural
Urban
Immigrant or refugee
LGBTQIA
Veteran/Military
Racial and ethnic minority
People with disabilities
Early Childhood
Youth
Seniors
Volunteer Totals:
Total Number of Licensed/Certified Clinical Volunteers:
*
Total Number of Non-Clinical Volunteers:
*
Breakdown of Volunteers:
Number of volunteer Clinical Providers (MD, NP, PA, DO):
Number of volunteer Dental Providers (DDS, RDH, Dental Assistants):
Number of volunteer Mental Health Providers (Counselors, Therapists, LCSW):
Number of volunteer Nurses (RN, LPN, Medical Assistants):
Number of volunteer Pharmacy Providers (RPh, Pharmacy Technicians):
Number of volunteer Medical/Dental/Nursing Students:
Number of volunteer Community Health Workers:
Gender
- please provide numbers for your volunteers. This is fashioned after Guidestar's questions.
Female
Male
Non-Binary (Identifying as any gender other than female or male)
Unknown or declined to state
We do not collect volunteer gender information
Race & Ethnicity
- please provide numbers for your volunteers. This is fashioned after Guidestar's questions.
Asian/Asian Americans/Pacific Islanders
Black/African American/African
Hispanic/Latino/Latina/Latinx
Native American/Indigenous
White/Caucasian/European
Multiracial/Multiethnic
Additional ethnicities
Unknown or decline to state
We do not collect volunteer race/ethnicity information
Paid Staff Totals:
Total Number of Paid Full-Time Licensed/Certified Clinical Staff:
*
Total Number of Paid Full-Time Non-Clinical Staff:
*
Number of Paid Part-Time Clinical Staff:
*
Number of Paid Part-Time Non-Clinical Staff:
*
Breakdown of Paid Staff:
Number of paid Dental Providers (DDS, RDH, Dental Assistants):
Number of paid Clinical Providers (MD, NP, PA, DO):
Number of paid Mental Health Providers (Counselors, Therapists, LCSW):
Number of paid Pharmacy Providers (RPh, Pharmacy Technicians):
Number of paid Nurses (RN, LPN, Medical Assistants):
Number of paid Community Health Workers:
Gender
- please provide numbers for your paid staff. This is fashioned after Guidestar's questions.
Female
Male
Non-Binary (Identifying as any gender other than female or male)
Unknown or declined to state
We do not collect paid staff gender information
Race & Ethnicity
- please provide numbers for your paid staff. This is fashioned after Guidestar's questions.
Asian/Asian Americans/Pacific Islanders
Black/African American/African
Hispanic/Latino/Latina/Latinx
Native American/Indigenous
White/Caucasian/European
Multiracial/Multiethnic
Additional ethnicities
Unknown or decline to state
We do not collect paid staff race/ethnicity information
Are your providers and/or volunteers offered or required to take Special Populations Response Training (SPRT)?
Yes
No
Patient-Related Questions:
Number of total Patient Visits in past year:
*
Number of New Patients in past year:
*
Number of Unduplicated Patients in past year:
*
Has your organization seen an increase in patients that are inquiring about care in the past year?
*
Yes
No
Other
If your organization has seen an increase in patients inquiring about care, what is the estimated percentage of increase?
1-%10
11%-20%
20%-40%
40%-50%
Over 50%
We have NOT seen an increase in patients inquiring about care.
Please select the following item that best describes your organization today:
*
We are currently at general capacity for patients and have a waiting list
We are currently at capacity ONLY for certain services and have a waiting list
We are NOT at capacity in general for our patients
What age ranges does your organization serve for patients? (select all that apply)
*
0-17
18-64
65+
Number of Patients reporting being:
Employed
Unemployed
We do not collect information on employment
Number of Patients who are:
Uninsured
Insured
Insured but Unable to Afford Care (underinsured)
We do not collect information on insurance status
Number of Patients who have been diagnosed or report having been previously diagnosed with:
Hypertension
High Cholesterol
Asthma
Diabetes
Current Smoker (tobacco/vaping)
Depression/Anxiety
Unknown
When looking at your diabetic patients, how many have an A1c under 9?
When looking at your diabetic patients, how many have an A1c at or below 7?
Patient Population Demographics
Please provide the following demographics information for your patient population. For any category your organization does not capture please leave blank.
These questions are modeled after the U.S. Census and the information required for Federally Qualified Health Centers, therefore we are gauging the data collection efforts by Free and Charitable Clinics with respect to gender, race and ethnicity in order to see how we align with these national reporting mechanisms.
Additionally, our funding partners are increasingly asking for information on these patient demographics as we develop programs on racial equity and health disparities.
We understand that not everyone may collect information separating ethnicity and race, therefore the second question in this section provides an opportunity for you to provide patient data that does not separate ethnicity from race.
Gender - please provide numbers for your total patient population
Number of Female Patients
Number of Male Patients
Number of Non-Binary (Identifying as any gender other than female or male)
Number of Transgender Females
Number of Transgender Males
Number of Patients that Choose Not to Identify
We do not collect patient gender information
Please select the way in which you collect patient information on race & ethnicity:
*Depending on your answer, different fields will appear after this question.
*
Option 1 - Race collected separately from ethnicity
Option 2 - Race combined with ethnicity when collected
We do not collect race & ethnicity for our patients (if selected, please skip the following "Option 1" and "Option 2" questions)
OPTION 1 - Race separated from ethnicity
Ethnicity - please provide the number of total HISPANIC patients within your patient population
Number of Hispanic Patients
Hispanic Patient Race: please provide the breakdown of patient races for your Hispanic patients
Number of Caucasian Patients
Number of Black or African American Patients
Number of American Indian or Alaska Native Patients
Number of Asian Patients
Number of Native Hawaiian or other Pacific Islander Patients
Number of Other Race Patients
Ethnicity - please provide the number of total NON-HISPANIC patients within your patient population
Number of Non-Hispanic Patients
Non-Hispanic Patient Race: please provide the breakdown of patient races for non-Hispanic patients
Number of Caucasian Patients
Number of Black or African American Patients
Number of American Indian or Alaska Native Patients
Number of Asian Patients
Number of Native Hawaiian or other Pacific Islander Patients
Number of Other Race Patients
OPTION 2 - Race combined with ethnicity
My organization does not collect information based on ethnicity, we collect the following:
Number of Caucasian Patients
Number of Black or African American Patients
Number of American Indian or Alaska Native Patients
Number of Asian Patients
Number of Native Hawaiian or other Pacific Islander Patients
Number of Hispanic/Latinx Patients
Number of Other Race Patients
Organizational Accreditation/Certification Status
Please note that answers to the following questions will be verified by the NAFC directly with the appropriate entities.
Would you like to participate in the NAFC's Quality Standards Program and fill out the next page in other to receive a seal of excellence?
*
Yes
No
Does your organization currently hold a NCQA Patient Centered Medical Home (PCMH) Recognition?
*If yes, please note that when you click on "next page" at the bottom, your survey will be submitted, you will receive an automatic NAFC Standards Seal and will not have to complete any additional information for NAFC standards.
*
Yes
No
If your organization holds a NCQA Patient Centered Medical Home (PCMH) Recognition, please upload a scanned copy of your certificate or official document showing your current status.
Is your organization currently a Federal Tort Claims Act (FTCA) sponsoring clinic?
*If yes, please note that when you click on "next page" at the bottom, your survey will be submitted, you will receive an automatic NAFC Standards Seal and will not have to complete any additional information for NAFC standards.
*
Yes
No
Has your organization been recognized as a Million Hearts Hypertension Control Champion?
Yes
No
Tell me more
State-Specific Questions:
If you are not part of the state association or in the state for the following statements, please click on “No” for each statement.
NORTH CAROLINA: My organization is a member in good standing with the North Carolina Association of Free & Charitable Clinics (NCAFCC) and currently holds NCAFCC Accreditation status. I understand that this will entitle me to reciprocity with the NAFC and I will receive a seal from the NAFC automatically. The NAFC will reach out to me at a later date with my seal.
*
Yes
No
SOUTH CAROLINA: My organization is a member in good standing with the South Carolina Free Clinic Association (SCFCA) and has satisfactorily completed and maintained the SCFCA's Standards for Certification. I understand that this will entitle me to reciprocity with the NAFC and I will receive a seal from the NAFC automatically. The NAFC will reach out to me at a later date with my seal.
*
Yes
No
VIRGINIA: My organization is a Full Member in good standing with the Virginia Association of Free and Charitable Clinics (VAFCC) and currently meets all standards associated with full membership status at VAFCC. I understand that this will entitle me to reciprocity with the NAFC and I will receive a seal from the NAFC automatically. The NAFC will reach out to me at a later date with my seal.
*
Yes
No
WISCONSIN: My organization is a member in good standing with the Wisconsin Association of Free & Charitable Clinics (WAFCC) and has satisfactorily completed and maintained the WAFCC’s Standards for Certification. I understand that this will entitle me to reciprocity with the NAFC and I will receive a seal from the NAFC automatically. The NAFC will reach out to me at a later date with my seal.
*
Yes
No
By checking this box, I attest that, to the best of my knowledge and belief, the statements provided on this form are true and correct.
*
I accept
Page #2 contains the NAFC's Quality Standards Questions for those of you who are eligible to fill this part out.
Once you click on "Next Page" below - you may see a screen that says "Your form has been submitted". This means you are done.
If you do not see page #2, and you need to go back into your page #1 to revise any answers, please email melanie@nafcclinics.org
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