Hospital Referral for USDA Technical Assistance

Hospital Information

Name of Hospital: *

Hospital Address: *

Hospital City: *

Hospital State: *

Hospital ZIP: *

Hospital Website: *

Is this hospital an existing RD borrower? *

Is this hospital a prospective RD borrower? *

Does this hospital serve a priority area (i.e. Persistent Poverty County, Distressed Community, Disaster Area, Opportunity Zone, etc.)? *

If Yes, please describe:

Would the Hospital's Board of Trustees benefit from a leadership certification program? *

Hospital CEO: *

CEO Email: *

CEO Phone Number *

Extension:

Please provide a brief reason for this referral to or urgent need for the USDA/NRHA Technical Assistance program: *

Is the hospital aware of this referral? (Yes/No) *

Name: *

Email: *

Relation to Hospital *

USDA Office Location (if applicable):

Phone: *

Extension: