Report Templates

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Author: 
Federal Office of Rural Health Policy (FORHP)

Report Templates consists of the required documents that must be submitted throughout the SHIP grant cycle to the Federal Office of Rural Health Policy (FORHP).

Topic Description Report Templates
FY 2020 Annual Report Template

This template is the attachment that you will upload to EHB for the FY 2020 Annual Report by 9/29/2021. The reporting period runs from 06/01/2020 – 05/31/2021. The following information will be requested:

  • Progress on the investments/activities for each hospital
  • Key outcomes on activities (if completed)
  • Amount of unobligated balance per hospital
  • Carryover amount and activity information (if applicable)
FY2021 SHIP Hospital Funding Spreadsheet - Attachment 4B - REVISED The purpose of this spreadsheet is to gather detailed information on all participating SHIP hospitals for FY2021. This spreadsheet has been revised to reflect the new funding amount: $12,836 per hospital.

FY 2021 SHIP Hospital Application SHIP coordinators may select SHIP Hospital Application A (short form) or SHIP Hospital Application B template for their hospitals to at the start of the new fiscal year and return it to their SHIP Coordinator. SHIP Coordinators need to keep all hospital applications on file.

FY 2020 Work Plan

 

 This is attachment #1 in the NCC Instructions. Use the FY 2020 Work Plan document to fill in activities, completion date, responsible staff and entity, progress/process measures and outcome/impact pertaining to the goals and objectives made during the FY 2020 budget period (June 1, 2020– May 31, 2021).

 

 
FY 2020 SHIP Activities Progress File This is attachment #2 in the NCC Instructions. During the FY 2020 budget period, state SHIP Coordinators should include each hospital, the FY 2020 investment/activity, and progress (complete, incomplete, or in progress), any change in investment/activity, and the impact/change or measure related to that activity.
FY 2021 Work Plan

This is attachment #3 in the NCC Instructions. Use the FY 2021 Work Plan document to fill in activities, completion date, responsible staff and entity, progress/process measures and outcome/impact pertaining to the goals and objectives for the upcoming budget period FY 2021 (June 1, 2021– May 31, 2022). The FY 2021 Work Plan should include any adaptions or updated progress/process measures for the upcoming year based upon FY 20 results.
FY 2019 Annual Report Template

This is the attachment to upload to EHB for the FY 2019 Annual Report by 9/30/2020. The reporting period is 06/01/2019 - 05/31/2020. It represents the following:

  • Progress on the investment/activities for each hospital
  • Key outcomes on activities (if completed)
  • Amount of unobligated balance per hospital
  • Carryover amount and activity information (if applicable)
 FY 2019 SHIP Annual Report Template

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,009,121 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.