2020-2021 Capital Improvement Program (CIP) Project Completion Report Form

The Project Completion Report is due when the project is completed and must be submitted/emailed no later than July 15, 2021.

Please review the CIP Project Completion Report Instructions below before completing to ensure that you have all the required documentation for report submission.

Since the form does not auto-save, it is highly recommended that the designated grantee staff completing the report have all necessary information available and ready before entering data into the online report form. To save time, it is suggested that the grantee first print the form, review, and obtain the required information, and then enter the information in the online form.
After reviewing and signing the Project Completion Report, the designated grantee staff may click the "Print Form" button to print a hard copy of the CIP report. Please Note: Once you hit submit you will not be able to print a hard copy of the report. The grantee MUST click the "Submit Form" button for the report to be submitted.

Please email RuralHealth@TexasAgriculture.gov or Trish.Rivera@TexasAgriculture.gov, 512-936-7875 with any questions or contact your regional coordinator listed below:

South Region - Eva Cruz: Eva.Cruz@TexasAgriculture.gov
West Region - Kathy Johnston: Kathy.Johnston@TexasAgriculture.gov
East Region - Trish Rivera: Trish.Rivera@TexasAgriculture.gov
North Region - Robert Shaw: Robert.Shaw@TexasAgriculture.gov
Central Region - Shari Wyatt: Shari.Wyatt@TexasAgriculture.gov
Panhandle Region - Ryan Horsak: Ryan.Horsak@TexasAgriculture.gov

Select CIP Grant Project Number: *

Tax ID Number: *

Legal Business Name of Hospital: *

Hospital DBA (N/A if not applicable): *

Hospital Address: *

Physical Address

Mailing Address

City State

Zip Code

County of Hospital *

SORH Region of Hospital *

Hospital Phone Number: *

Area Code Phone Number

Administrator/CEO Name *

First Name Last Name

Administrator/CEO E-mail: *

CIP Project Director Name: (Individual Responsible for Managing CIP-Funded Project) *

First Name Last Name

CIP Project Director E-mail: *

Amount Awarded: *

Maximum Award Amount: $75,000

Amount Matched *

Note: Required Match is 25% of the CIP GRANT AMOUNT (Grant Funds Requested), not total project cost

Type of CIP Project Conducted by Grantee Hospital: *

Equipment Contract for Non-Medical Services Patient Transportation Construction

Definition of Types of CIP Projects:

· Equipment is defined by TDA as non-expendable personal property with a unit cost of more than $5,000 and a useful life of more than one year.

· Contracts for non-medical services includes, but is not limited to, contracts for designing, engineering, supervising, surveying, and other expenses incidental to the acquisition, construction, or improvements of new hospitals.

· Patient transportation includes, but is not limited to, contracts for patient transportation projects such as the purchase of ambulances.

· Construction includes, but is not limited to, contracts for any construction of building on the hospital or outbuildings, remodel projects, additions, etc.

Is the CIP Project Complete? *

Yes No

CIP Project Completion Date: *

If "No," what activities still need to be performed? When will the project be completed?

What was the initial purpose of your project? *

Did the purpose of your project change during the implementation? If so, please explain? (changes MUST receive written prior approvals from the SORH). *

Describe any significant differences between budgeted amount in the original application and the actual amount noted above (significant changes MUST receive written prior approvals from the SORH). *

What were the outcomes of your project? How did it impact your community/hospital? If possible, please provide quantitative numbers. (Ex: New cardiology equipment allowed us to serve ## many more patients, roof repair allowed us to open # closed patient rooms, a remodeled kitchen allowed for safer and better food service for patients and staff.) *

The CIP grant requires matching expenditures equal to or greater than 25% of the total grant amount (CIP Funds Requested). For example, if you are requesting $75,000 you must contribute at least $18,750, showing a total project cost of $93,750. When awarded, grant recipients will be held accountable for maintaining the required 25% match of the awarded grant amount. In the event the grant recipient's match is reduced below 25%, the Department may proportionally reduce the amount of the CIP grant funds.

Vendor and equipment quotes, and/or contractor estimates, etc. MUST be uploaded below in Section E. Attachments of Supporting Documentation.

How to Calculate CIP Grant Amount & Matching Funds:

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If Total Project Cost is < (less than) $93,750: Calculate by:

Total Project Cost divided by 1.25 = CIP grant amount, remaining is matching funds

Example: Total Project Cost = $65,000

$65,000 / 1.25 -- $52,000 (CIP Grant Amount)

$65,000 - $52,000 (CIP Grant Amount) = $13,000 (Matching Funds)

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If Total Project Cost is > (greater than) $93,750: Calculate by:

Total Project Cost minus (-) $75,000 (maximum CIP grant amount) = Matching Funds

Example: Total Project Cost = $200,000

$200,000 - $75,000 = $125,000 (Total Matching Funds)

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CIP Grant Project Budget Summary: *

	CIP Funds Requested	Matching Funds	TOTAL
A. Equipment
B. Contract for Non-Medical Services
C. Patient Transportation
D. Construction
TOTAL DIRECT COSTS

Invoices *

Browse Files

Proof of Payment *

Browse Files

Project Photos - Please provide 1-3 photos of your project in separate .pdf or .jpeg files *

Browse Files

It is hereby certified that all activities undertaken by Grant Recipient with funds provided under the Rural Health Facility Capital Improvement Program (CIP) Grant Agreement have, to the best of my knowledge, been carried out in accordance with the Grant Agreement, and that the information set forth in this report is, to the best of my knowledge, true and correct as of this date.