RHOA Form : Translational Health Research Center : Texas State University

First Name *

Last Name *

Email Address *

Phone Number

Name of the hospital you are affiliated with *

County where the hospital is located *

Your title or affiliation with the hospital (CFO, CEO, Board member, etc.) *

Zip/ Postal Code

Does the hospital meet any of the following criteria? Select all that apply. *

Received a financial stabilization grant

Obtained an emergency hardship grant within the past three years

Designated as a Rural Emergency Hospital or actively pursuing this designation from the Centers for Medicare and Medicaid Services

Experienced executive leadership turnover over the last two years

Sole hospital in the county

Not sure / None of the above

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