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.
  • - -
  • - -
  • Contacts

    The following contacts will automatically receive official NAFC communications.
  • Organization Structure

  • 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
  • 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

  • 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
  • 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
  • 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
  • Social Determinants of Health

  • We screen for this
    Food Insecurity
    Housing
    Education
    Employment
    Finance
    Literacy
    Transportation
    Child Care
    Personal Safety
    Utilities
    Ability to afford prescribed medications
  • 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
  • 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
  • Volunteer Totals:

  • Breakdown of Volunteers:

  • Female
    Male
    Non-Binary (Identifying as any gender other than female or male)
    Unknown or declined to state
  • 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
  • Paid Staff Totals:

  • Breakdown of Paid Staff:

  • Female
    Male
    Non-Binary (Identifying as any gender other than female or male)
    Unknown or declined to state
  • 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

  • Patient-Related Questions:

  • Employed
    Unemployed
  • Uninsured
    Insured
    Insured but Unable to Afford Care (underinsured)
  • Hypertension
    High Cholesterol
    Asthma
    Diabetes
    Current Smoker (tobacco/vaping)
    Depression/Anxiety
  • 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.
  • 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
  • OPTION 1 - Race separated from ethnicity

  • Number of 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
  • Number of 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

  • 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.
  • 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.
  • 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


  • 1 / 2