General Information. * Are you a hospital or an LHD. Hospital LHD
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1 General Information * Are you a hospital or an LHD Hospital LHD
2 Hospital Information * Hospital Name Year(s) of Current CHNA Year(s) of current Improvement Strategies/Plan What counties are represented/served in this assessment/plan? Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas
3 Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot
4 Collaboration - Hospital with LHD (1) Did you collaborate with local health department(s) during your assessment/planning process? Yes No If yes, please select the LHD(s) that you collaborated with on your assessment/planning Adams County Health Geauga County General Health Ottawa County Health Allen County Combined Health Alliance City Health Ashland City Health Ashland County Health Ashtabula City Health Ashtabula County Health Athens County Health Auglaize County Health Greene County Combined Health Hamilton City Health Hamilton County General Health Hancock County Health Harrison County Health Henry County General Health Highland County Health Paulding County Health Perry County General Health Pickaway County General Health Pike County General Health Piqua City Health Portage County Combined General Health Portsmouth City Health Belmont County General Health Hocking County Health Preble County General Health Belpre City Health Brown County Health Butler County Health Cambridge Guernsey County Health Canton City Health Carroll County General Health Champaign Health Cincinnati City Health Clark County Combined Health Clermont County Health Holmes County General Health Huron County General Health Ironton City Health Jackson County Health Jefferson County General Health Kent City Health Kenton-Hardin Local Health Knox County Health Lake County General Health Lawrence County Health Public Health - Dayton and Montgomery County Putnam County Health Ross County Health Salem City Health Sandusky County Combined General Health Scioto County Health Seneca County General Health Shaker Heights City Health Shelby City Health Cleveland of Public Health Clinton County Health Licking County Health Logan County Health Lorain County General Health Sidney Shelby County Health Springdale City Health
5 Columbiana County General Health Columbus Public Health Conneaut City Health Coshocton City Health Coshocton County General Health Crawford County General Health Cuyahoga County Health Darke County General Health Defiance County General Health Delaware General Health Madison County-London City Health Mahoning County General Health Mansfield Ontario Richland County Health Marietta City Health Marion Public Health Massillon City Health Medina County Comb General Health Meigs County Health Mercer County Health Miami County Health Stark County Combined General Health Steubenville City Health Summit County General Health Toledo Lucas County Health Trumbull County Health Tuscarawas County General Health Union County Health Van Wert County General Health Vinton County Health Warren City Health East Liverpool City Health Erie County General Health Fairfield County of Health Fayette County Combined Health Franklin County Board of Health Fulton County Health Galion City Health Gallia County General Health Middletown City Health Monroe County Health Morgan County General Health Morrow County Health New Philadelphia City Health Noble County Health Norwood City Health Oakwood City Health Warren County Combined Health Washington County Health Wayne County Health Williams County Combined Health Wood County Combined General Health Wyandot County General Health Youngstown City Health Zanesville-Muskingum County Health
6 Collaboration - Hospital with LHD (2) Did you collaborate with the local health department(s) in your market service area during their assessment/planning process? Yes No If yes, please select the LHD(s) that you collaborated with on their assessment/planning Adams County Health Geauga County General Health Ottawa County Health Allen County Combined Health Alliance City Health Ashland City Health Ashland County Health Ashtabula City Health Ashtabula County Health Athens County Health Auglaize County Health Greene County Combined Health Hamilton City Health Hamilton County General Health Hancock County Health Harrison County Health Henry County General Health Highland County Health Paulding County Health Perry County General Health Pickaway County General Health Pike County General Health Piqua City Health Portage County Combined General Health Portsmouth City Health Belmont County General Health Hocking County Health Preble County General Health Belpre City Health Brown County Health Butler County Health Cambridge Guernsey County Health Canton City Health Carroll County General Health Champaign Health Cincinnati City Health Clark County Combined Health Clermont County Health Holmes County General Health Huron County General Health Ironton City Health Jackson County Health Jefferson County General Health Kent City Health Kenton-Hardin Local Health Knox County Health Lake County General Health Lawrence County Health Public Health - Dayton and Montgomery County Putnam County Health Ross County Health Salem City Health Sandusky County Combined General Health Scioto County Health Seneca County General Health Shaker Heights City Health Shelby City Health Cleveland of Public Health Clinton County Health Licking County Health Logan County Health Sidney Shelby County Health Springdale City Health
7 Columbiana County General Health Columbus Public Health Conneaut City Health Coshocton City Health Coshocton County General Health Crawford County General Health Cuyahoga County Health Lorain County General Health Madison County-London City Health Mahoning County General Health Mansfield Ontario Richland County Health Marietta City Health Marion Public Health Massillon City Health Stark County Combined General Health Steubenville City Health Summit County General Health Toledo Lucas County Health Trumbull County Health Tuscarawas County General Health Union County Health Darke County General Health Defiance County General Health Delaware General Health Medina County Comb General Health Meigs County Health Mercer County Health Van Wert County General Health Vinton County Health Warren City Health East Liverpool City Health Erie County General Health Fairfield County of Health Fayette County Combined Health Franklin County Board of Health Fulton County Health Galion City Health Gallia County General Health Miami County Health Middletown City Health Monroe County Health Morgan County General Health Morrow County Health New Philadelphia City Health Noble County Health Norwood City Health Oakwood City Health Warren County Combined Health Washington County Health Wayne County Health Williams County Combined Health Wood County Combined General Health Wyandot County General Health Youngstown City Health Zanesville-Muskingum County Health
8 Collaboration - Hospital with LHD (3) Do you and the LHD(s) in your service area work on your assessments/plans at the same time? Yes No
9 Alignment - Priority Areas For these questions, please consider your current CHNA/Improvement Strategies as they related to the State Health Improvement Plan (SHIP). Visit for more details. Do your priority areas/focus currently align with any of the state SHIP priorities? Yes No Mental Health / Addiction Chronic Disease Maternal & Infant Health
10 Alignment - Priority Outcomes Next, please consider if your current priorities align with the priority topics/priority outcomes in the SHIP. For additional information, please refer the Priority Community Strategy and Indicator Toolkit: Mental Health & Addiction Yes No Reduce Depression Reduce Suicide Deaths Reduce Drug Dependence or Abuse Reduce Unintentional Drug Overdose Deaths Chronic Disease Yes No Reduce Heart Disease Reduce diabetes Reduce child asthma morbidity Infant Mortality Yes No Reduce Preterm Births Reduce low birth-weight births Reduce infant mortality
11 Priority Outcomes - Indicators MHA Are you monitoring one of the indicators for the following priority areas? Select from the list below the indicators that you are currently monitoring. Mental Health & Addiction Reduce Depression - Are you monitoring either of these indicators? Adolescent depression: Percent of persons age who experienced a major depressive episode within the past year Adult depression: Percent of persons age 18+ who experienced a major depressive episode within the past year Reduce Suicide Deaths - Are you monitoring this indicator? Suicide deaths: Number of deaths due to suicide per 100,000 population (age-adjusted) Reduce drug dependence or abuse - Are you monitoring this indicator? Reduce past-year illicit drug dependence or abuse among ages 12+ Reduce unintentional drug overdose deaths - Are you monitoring this indicator? Unintentional drug overdose deaths: Number of unintentional deaths due to drug overdoses per 100,000 population (ageadjusted)
12 Priority Outcome Indicators - CD Are you monitoring one of the indicators for the following priority areas? Select from the list below the indicators that you are currently monitoring. Chronic Disease Reduce Heart Disease - Are you monitoring these indicators? Coronary heart disease: Percent of adults ever diagnosed with coronary heart disease Heart attack: Percent of adults ever diagnosed with heart attack Hypertension: Percent of adults ever diagnosed with hypertension Reduce Diabetes - Are you monitoring these indicators? Diabetes: Percent of adults who have been told by a health professional that they have diabetes Prediabetes: Percent of adults who have been told by a health professional that they have prediabetes Reduce child asthma morbidity - Are you monitoring this indicator? Hospital admissions for pediatric asthma, per 100,000 children ages 2-17 (excludes patients with cystic fibrosis or abnormalities of the respiratory system, and transfers from other institutions)
13 Priority Outcome Indicators - MIH Are you monitoring one of the indicators for the following priority areas? Select from the list below the indicators that you are currently monitoring. Maternal and Infant Health Reduce Preterm births - Are you monitoring these indicators? Total preterm births: Percent of live births that are preterm: <37 weeks gestation Very preterm births: Percent of live births that are very preterm: <32 weeks gestation Reduce low birth weight - Are you monitoring this indicator? Low birth weight births: Percent of births in which the newborn weighed <2,500 grams Reduce infant mortality - Are you monitoring these indicators? Infant mortality: Rate of infant deaths per 1,000 live births Neonatal infant mortality: Rate of neonatal infant deaths per 1,000 live births Post-neonatal infant mortality: Rate of post-neonatal infant deaths per 1,000 live births Are you an LHD or Hospital completing this survey? Hospital LHD
14 Hospital Additional Comments Do you have additional comments/notes about the following you are submitting? Additional notes about CHNA Additional notes about Improvement Strategies/Plans Additional notes about Schedule H/Attachments Other Comments Optional Contact Information Name Company Address Phone Number
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