4A (Expenses $ 929689482 including grants of $ 83326957) (Revenue $ 1754932548)
Cook Children's Medical Center is the cornerstone of Cook Children's Health Care System. This 444-bed facility is home to top medical minds, advanced technologies, family-centered treatments and leading-edge clinical research, all designed to fulfill the System's Promise to improve the health and well-being of every child. Nationally recognized services such as the Level IV Neonatal Intensive Care Unit, the Jane and John Justin Neurosciences Center and the hematology and oncology center are leading the way in providing the highest level of care to families who travel to the medical center from all across Texas and the United States, as well as internationally. From complicated surgeries and Level II trauma care to physical therapy and behavioral health services, the medical center offers a variety of services and amenities to meet the unique needs of every patient and family. It is one of only 10 freestanding children's hospitals in the world to achieve Magnet designation with three consecutive re-designations from the American Nursing Credentialing Center, most recently in February 2021. Viral Surge On the heels of the COVID-19 pandemic, the country experienced an unseasonal round of respiratory syncytial virus (RSV) followed by the return of influenza and other seasonal viruses that hit children hard and, subsequently, strained pediatric hospitals. The medical center had to be nimble, flexible and quick to adjust to each new viral surge. To reduce the spread of illness, Cook Children's maintained safety protocols put into place early in the pandemic, such as masking, limiting visitors and instituting work-from-home plans. The medical center released weekly RSV and flu numbers to the public and held press conferences with Cook Children's physicians. It also asked for the community's help in limiting the spread of illness, taking children to the appropriate provider based on their condition (e.g. pediatrician versus urgent care versus ER) and encouraged patience during long wait times in busy ERs and urgent care centers. Telehealth remains a critical resource for the hospital, especially during times of intense viral spread. In the early days of COVID-19, Cook Children's took steps to increase its bandwidth to support the explosive growth in virtual health visits. The year's virtual health visits totaled approximately 67,000 across all of Cook Children's Health Care System. Pandemic Inspires Improvement Out of the challenges of the pandemic emerged a stronger organization better equipped for the future. In early FY22, Cook Children's opened a new six-bed Infectious Disease Unit designed to treat the sickest patients while also protecting staff and the community from the spread of illness. It includes private patient rooms with private bathrooms, specialized air ventilation systems, dedicated areas for visitors and staff to put on and take off personal protective equipment and technology that allows technicians to closely monitor a patient without having to be directly by the patient's bedside. The expansion includes a 24-hour solutions center inspired by lessons learned from the pandemic. This center will operate year-round to serve as a one-stop shop for requesting assistance with a facility or operations issue at Cook Children's Health Care System. Raising Joy Cook Children's 2021 JOY campaign-an ongoing series of articles that addressed and educated readers on children's rising mental health care needs-grew to include a new podcast featuring honest conversations about the mental well-being of kids and teens. The Raising Joy Podcast premiered in March 2022, and aired a total of 35 episodes throughout the year. Topics covered everything from child trafficking to drug use to body image to parents sharing their personal experience losing a child to suicide. The podcast is hosted by Cook Children's senior vice president and chief communication, inclusion, diversity and equity officer, and Cook Children's medical director of psychiatry outpatient services and partial hospitalization program. Safety Saves Lives By April 2022, 17 children had been treated for drownings at Cook Children's since the start of the year. That includes three fatalities. This was an alarming increase in the number of drownings compared to January through May in the previous five years. In response, Cook Children's communications team, together with the Center for Children's Health, led by Cook Children's, ramped up its drowning prevention education efforts in tandem with its ongoing Lifeguard Your Child water safety program. Several articles about drowning prevention, the importance of swim lessons, proper fit of life vests and water safety resources were published to Cook Children's Checkup Newsroom and social media accounts. In May, the medical center erected a powerful display outside on its north lawn as a visual reminder to Lifeguard Your Child. Fifteen swimsuits and five rubber duckies hung on a clothesline, representing children who were treated for drowning injuries at the hospital since the beginning of 2022. Each swimsuit matched the age and gender of the swimming pool drowning patients treated up to that point in the year. The rubber duckies represented the five children who drowned in bathtubs. Cook Children's Aim for Safety program zeroed in on a new way to educate families on gun safety using an interactive kiosk that teaches children what to do if they discover a firearm in a home - all while reinforcing safe-storage techniques for adult gun owners. The mobile kiosk, which stands more than 7-feet high and resembles a giant smartphone, rolled out in December 2021 at Defender Outdoors, a sports shooting and outdoors equipment retailer in Fort Worth. As part of a first-time collaboration with Cook Children's, the kiosk was placed near the check-out registers in hopes it attracts the attention of parents and children alike. The Aim for Safety educational kiosk - activated by touch - uses advanced technology to engage and teach children as they progress through four levels, stumbling upon unsecured guns hidden in places such as cabinets and drawers while moving through a virtual home. If they find a gun, they must correctly answer questions on how to safely handle the situation in order to progress through the program. Other gun safety-related questions are asked as objects in the rooms are found and touched. The program emphasizes three steps: Safe Storage. Safe Children. Safe Play. New and Improved Cook Children's Medical Center announced its development of a clinical care model that brings together specialties for more seamless health care. The Jane and John Justin Institute for Mind Health will bring Cook Children's Jane and John Justin Neurosciences Center, Cook Children's Division of Behavioral Health and the Child Study Center under one collaborative roof to provide easily accessible, well-coordinated and comprehensive care for children with disorders affecting the nervous system. The Justin Institute will be located in the Dodson Specialty Building on the medical center campus and is slated to open Spring 2023. Exceeding Expectations Even while operating under the cloud of the pandemic and challenging viral seasons, CCMC continued to pursue quality, safety and communication. Patient experience scores exceeded the Children's Hospital Association (CHA) average, earning employees a performance bonus. Cook Children's was one of five children's hospitals from across the country selected to present its success in improving workplace safety at the 2022 Solutions for Patient Safety (SPS) Fall National Learning Conference. Over the past five years, with collaboration from SPS, Cook Children's has worked to reduce the number and severity of employee injuries in three focus areas-slips, trips and falls; patient behavior events; and overexertion injuries caused by handling patients, soiled linen and trash. At the conference, several Cook Children's executives, board members, leaders and clinical staff reported on the health system's journey to a safer and healthier workplace. In February 2022, Jill Koss, Cook Children's director of Family Support Services, was honored by Crown Council, an organization associated with Teammates for Kids, for her work championing Child Life Zones at Cook Children's and other hospitals throughout the country. At the recognition event, Koss was surprised with a recorded video message from Country music singer and songwriter Garth Brooks, who delivered an emotional thank you for Koss' tireless work advocating for interactive spaces designed to foster the creative arts for pediatric patients and siblings.

SCHEDULE H, PART V, SECTION B, LINE 5
Input from representatives of the community: The initial Cook Children's Community-Wide Children's Health Assessment and Planning Survey (CCHAPS) was conducted in 2009 and every three years thereafter (2012, 2015, 2018 and 2021). Our methodology varies slightly among assessment years but always includes gathering data from multiple sources representing our community. Overall, our Community Health Needs Assessment (CHNA) methodology includes a survey of parents of children ages 0-17, a community leader survey, and focus groups outlined in the table below. We also gather feedback from community coalition members through facilitated discussions at regular meetings and at eight child health summits that we host to present the data to our various communities. In addition, Cook Children's collects data from publicly available sources to supplement perceptions of children's health obtained through the parent and community leader surveys, focus groups and/or community meetings. The 2021 CHNA parent survey was administered through an outside vendor (ETC Institute) to a statistically representative sample of parents with children ages 0-17 living in our primary service region (Collin, Denton, Grayson, Hood, Johnson, Parker, Tarrant, and Wise counties). The large sample size (5,715 completed surveys) provides statistically representative results applicable to all eight counties individually and collectively with a low margin of error (+/- 1.3%; 95% CI). The survey is administered through mail, telephone, and internet communications and ETC monitors responses to ensure that representation is similar to general population demographics in terms of total population in each geographic area, race/ethnicity, marital status, income, and education level. In order to assess the health of children living in families that are traditionally underrepresented in mail and telephone surveys, a research team from the Evaluation and Outcomes Division of My Health My Resources of Tarrant County (MHMRTC) administered the parent survey to an intentional sample of caregivers within families experiencing homelessness in shelters or within families with at least one undocumented member at several Tarrant County homeless shelters (229 completed surveys). A team from University of North Texas Health Science Center at Fort Worth's School of Public Health conducted six virtual focus groups and one interview with parents (total of 22 parents/caregivers) across the eight-county service area. Community partners and program staff within the Center for Children's Health helped advertise and refer participants via email. These focus groups provided an opportunity for parents and caregivers to share additional information beyond questions within in the parent survey. Priority topics within these focus groups included asthma, oral health, mental health, healthy lifestyles, injury prevention, parenting support, COVID-19 and equitable access to care. The Center for Transforming Lives conducted a survey of families with children from birth to age 17 who were living within motels or extended-stay properties throughout Tarrant County from February to October 2021. Seventy families completed the anonymous surveys on-site at the motel locations. ETC Institute also conducted a survey with community leaders to obtain their feedback about the status of children's health. Surveys were mailed to 1,881 community leaders representing city and county governments, public agencies, not-for-profit organizations, independent school districts, faith based/clergy, and health care professionals. We received 306 responses (16% response rate). A complete list of who received the opportunity to participate in the leader survey is available upon request. Virtual interviews with 20 community leaders across the eight-county service area were also conducted. Leaders were recruited based on their expertise and diverse roles within the community. Interviewees discussed pressing issues or concerns in the community, providing additional context for the community leader and parent survey findings. Priority topics discussed during the interviews included the impact of COVID-19, mental health, ACEs, housing and food security, healthy lifestyles, injury prevention, and equitable access to health care. Based on the 2009 initial assessment results, Cook Children's Board of Trustees prioritized children's health issues identified by parents and community leaders and findings from subsequent CHNA processes in 2012, 2015, 2018, and 2021 confirmed the importance of these issues for continuing focused intervention: - Equitable access to health care - Oral Health - Mental Health - Healthy Lifestyles (obesity prevention) - Parenting and Family Support (abuse and neglect prevention) - Injury Prevention - Asthma Cook Children's continues to use the 2021 CHNA findings to assess parent and community leader perceptions of children's health needs and to inform our community health outreach and community engagement efforts. The 2024 CHNA is currently in development and will be completed and posted by September 30, 2025.

Schedule H, Part V, Section B, Line 6a
CHNA CONDUCTED WITH OTHER HOSPITAL FACILITIES: This 2021 Community Health Needs Assessment report is intended to serve as a joint assessment for the main Cook Children's Medical Center in Fort Worth and the new Cook Children's Medical Center in Prosper, opening in the fall of 2022. The Fort Worth Medical Center's primary service area encompasses Denton, Hood, Johnson, Parker, Tarrant and Wise counties. The Prosper Medical Center serves the primary counties of Collin, Denton and Grayson. Our 2021 assessment intentionally collected data in Collin and Grayson counties to represent those communities in the Prosper service area. Denton County falls within both the Fort Worth and Prosper service areas.

SCHEDULE H, Part V, Section B, Line 6b
Other Organizations other than Hospital Facilities: External vendors used to conduct the parent and community leader surveys included The Center for Transforming Lives, ETC Institute, Inc., My Health My Resources of Tarrant County, and University of North Texas Health Science Center. No other organizations were involved other than these contracted surveyor entities and no other organizations are able to use this assessment to fulfill CHNA requirements.

SCHEDULE H, PART V, SECTION B, LINE 11
HOW WE ARE ADDRESSING SIGNIFICANT NEEDS: Cook Children's created the Center for Children's Health in 2011 to provide an infrastructure for using children's health assessment data to guide community programs and stakeholder collaborations that prevent illness, disease and injuries for children. The center oversees a regular community health needs assessment, community research and community health outreach. All three categories of Center activities are focused on increasing access to preventive services for underserved populations. The Center for Children's Health develops strategies for addressing targeted children's health priorities through research and an infrastructure that supports effective delivery of community and family services. Our services are data driven, evidence-informed and provided using high standards of community practice and service delivery. Recognizing that Cook Children's cannot solve complex children's health needs alone, we lead coalitions and support partnerships in every county within our primary service region to involve community partners in identifying health needs, and developing and implementing sustainable solutions. Collaborations are structured according to principles that research indicates are effective characteristics for successful community collaborations, including a commitment to using strategic plans to guide implementation of strategies, diverse representation within each community, and facilitating decisions guided by members according to formal coalition bylaws and meeting guidelines. Collaborations led by the Center for Children's Health include: - ACEs Task Force - Children's Oral Health Coalition - Lifeguard Your Child (Drowning Prevention Campaign) - Healthy Children Coalition of Parker County - Hood County for Healthy Children - Johnson County Alliance for Healthy Kids - Safe Baby Sleep Council - Safe Kids North Texas-Fort Worth - SaVe a Smile - Wise Coalition for Healthy Children - Wellness Alliance for Total Children's Health of Denton County 2021 CHNA parent and community leader survey findings support Cook Children's continued focus on family outreach programs that address the children's health issues identified in our initial parent survey process in 2009. The family services addressing priority children's health needs are provided using evidence-based/informed practices, including strict adherence to regulatory requirements, implementing proven program designs, obtaining appropriate staff certifications or licensures, providing adequate supervision, practicing accurate and confidential record-keeping, and conducting ongoing formal evaluation. Recognizing the need to improve access to care for vulnerable populations, the Center for Children's Health focuses all programming listed in the following sections to families identified as high-risk either due to low income or high prevalence of health risk factors. Equitable Access to Health Care Goal: Improve overall health for children and increase equitable access to quality health care - Ensure that C4CH programs and community involvement exemplify Cook Children's Promise. Community Strategies - Monitor and identify priority children's health issues in Cook Children's 6-county FWSA/3-county PSA to guide equitable service delivery program designs > Held 6 local and 2 regional CHNA Summits to share findings from the 2021 CHNA. > Rolling data collection is in progress for the 2024 CHNA by administering the parent survey among a purposeful sample of caregivers and families across the 8-county region. - Draw on the power of community partnerships to increase the reach for equitable health care information and services to disproportionally impacted populations (C4CH Coalitions) > The Homeless Initiative addresses unmet health and psycho-social needs of children living in three shelters in Tarrant County by providing a medical home and a case management model to coordinate health and social services. > Cook Children's is regularly represented at community initiatives throughout our region addressing various child health issues. > The Center for Children's Health distributed 332,529 educational resources and 181,567 prevention tools through community events and community partners in FY22. - Lead community coalitions with multi-sector, geographically diverse membership. > The Center for Children's Health led over 800 community events and engaged over 600 community partners to promote the health and safety of children. - Maintain focus of C4CH service delivery programs designs on the principles of community collaboration, evidence-based information and practices, and reducing health disparities and inequities. - The Center for Children's Health contributes funding to the Immunization Collaboration of Tarrant County to provide easy access to immunizations for children from low-income families in Tarrant County. The collaboration hosts a multi-week event during August and September, with the help of nearly 100 volunteers to immunize approximately 6,000+ children each year. - The Center for Children's Health provides regular communication about health information to families and community partners through Checkup Magazine, YouTube videos, and presentations. - The Center maximizes the power of Cook Children's integrated health system by developing close partnerships with Neighborhood Clinics, Cook Children's Health Plan, and other departments offering case management services to distribute health and wellness messages and prevention tools. - The Center for Children's Health and Cook Children's Health Plan expanded their partnership with the addition of a C4CH/CCHP Liaison. This liaison has held multiple stakeholder meetings, educated children and families on prevention efforts to help keep their children healthy and safe, and assisted with resource distributions. In FY22, CCHP staff distributed 19,714 C4CH resources to members and potential members and provided 168 hours of support at C4CH meetings and events. - Community Health Workers (CHWs) are an integral piece to the success of several C4CH programs including Build-a-Bridge, Save-A-Smile, and Healthy Homes by connecting families to needed resources and support services to increase access to care. In FY22, CHWs provided 5,660 social services to families to help them meet basic needs and address social determinants of health and were responsible for 477 community referrals provided to families connecting them to basic needs and health services. CHWs, along with other C4CH staff, served 21,616 children, families, and partners. Additional information related to increasing access to care is also addressed throughout each of the remaining six focus areas discussed below. Oral Health Goal: Improve child oral health - Respond to the urgent needs of children at increased risk of poor oral health Community Strategies - Lead and sustain the Save a Smile Advisory Committee; and the Children's Oral Health Coalition (COHC) to plan and implement oral health collaborative interventions. The coalition's Legislative Advocacy committee monitors state and national legislative issues, especially those supporting expanded access to dental care for low-income children. - Develop and distribute evidence-informed oral health resources to educate families, medical/dental providers and other community partners. - Continue Save a Smile programming to conduct limited oral health evaluations for low-income children; identify those with acute dental problems in targeted schools; and provide comprehensive social and dental treatment services. - Provide evidence-based training to caregivers and children; pregnant women; school nurses; medical/dental providers; and other community partners. - Facilitate and track community-level oral health screening outcomes. - Reduce barriers to oral health care for pregnant teens and women. - Explore potential partnership with Renaissance Dental Clinic to expand patient family education opportunities. - Support community awareness campaigns and events to encourage good oral health Mental Health Goal: Increase access to services for child mental health and well-being - Respond to the increasing critical need for mental health services to serve children Community Strategies - Lead and sustain the Wellness Alliance for Total Children's Health (WATCH) to plan and implement mental health collaborative interventions, targeting high-risk populations. - Sustain a strong community network of quality mental health services to support mental health services and treatment (Mental Health Connection). - Provide professional development opportunities for mental health providers who will share skills, knowledge, and tools with colleagues and caregivers within their reach (Wellness Workshops). - Develop and implement evidence-informed education and interventions for caregivers, children and adolescents to expand the reach of mental health messaging and strengthen connections to health care and commun

Schedule H, Part V, Section B, lines 7a & 10a
CHNA & Implementation strategy availability: The CHNA and implementation strategy are available upon request and at the following address: www.cookchildrens.org/about/community-outreach/pages/community-health-need s-assessment.aspx

Schedule H, Part V, Section B, lines 16a, 16b & 16c
Financial assistance documents: The financial assistance policy, application and plain language summary are available at the following address: https://www.cookchildrens.org/patients/billing-insurance/pages/financial-a ssistance.aspx

SCHEDULE H, PART III, SECTION A, LINE 2
Bad debt expense: We record self-pay accounts at the full expected amount. Each account goes through the collection process as necessary. An allowance is established based on historical experience.

SCHEDULE H, PART III, SECTION A, LINE 3
Bad debt as a community benefit: Bad debt, in whole or in part, should be included in community benefit given the tangible and measurable benefit of the underlying services provided to, primarily, underserved members of our community. For instance, we have a significant non-insured, undocumented worker population that may not participate in the charity or medically indigent discount qualification process due to concerns about their immigration status. We provide critical inpatient, emergency room, and outpatient services to this demographic for little or no reimbursement and without regard for their ability to pay, but receive no community benefit consideration. At a minimum, hospitals should have the opportunity to delineate how much bad debt stems from non-insured patients and then be given community benefit consideration for the cost burden associated with providing these needed services knowing that we have already done all we can with regard to screening patients for charity and medically indigent discounts and written the patients' balances off as such.

SCHEDULE H, PART III, SECTION A, LINE 4
Bad debt footnote: Footnote disclosure regarding the treatment of bad debts is located on page 20 of the most recent audited financial statements attached to this form.

SCHEDULE H, PART III, SECTION B, LINE 8
Medicare shortfall and cost reported: The Medicare shortfall should be considered community benefit since it is representative of the non-covered cost of patient care that hospitals are using to justify the need for their tax exempt status. Presenting the Medicare shortfall in the community benefit section allows regulators and the public to see the unfunded costs of services that hospitals provide to community members. This presentation would help the community better understand that in the absence of a tax exempt status (which in effect is granted to them by the public), the hospitals would have to look to the community to fund the shortfall or risk losing valued hospital services. The ratio of cost to charges used in the calculation of costs for Medicare was taken from the Medicare cost report.

SCHEDULE H, PART III, SECTION C, LINE 9B
COLLECTION PRACTICES: THE HOSPITAL DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE.

SCHEDULE H, PART VI, LINE 2
Needs assessment: Although various departments within Cook Children's periodically conduct patient needs assessments for specific medical specialties, the parent survey for our Community Health Needs Assessment, also known as the Community-wide Children's Health Assessment & Planning Survey (CCHAPS) as reported in Part V, Section B-is the only community-wide children's health needs assessment conducted by our health system.

SCHEDULE H, PART VI, LINE 3
Patient education of eligibility for assistance: English and Spanish versions of a one-page document explaining the charity care offered at Cook Children's are posted in each of the patient registration areas, the emergency room, urgent care, and medical office building. This document includes information on the following: 1. How one might qualify for financial assistance; 2. Explains qualification is determined by family size and income; and, 3. Guides families to contact the patient accounting department to apply for financial assistance. A financial counselor will assist all self-pay inpatients, observation stays and scheduled procedures, screening them for various government programs, such as Medicaid and Chip. In addition, a financial counselor will assist any patient that presents to registration for financial assistance, providing them with a Medicaid application and reviewing the charity policy. Patient representatives and Case Management personnel also direct families to the patient registration staff when they need financial assistance. In addition, the financial assistance policy, explanation of amounts generally billed and the charity application are posted on the Cook Children's website at www.cookchildrens.org. The charity application is posted in both English and Spanish versions.

SCHEDULE H, PART VI, LINE 5
PROMOTION OF COMMUNITY HEALTH: In FY2022, the Center for Children's Health led 812 health outreach events serving over 33,000 children, families, and community partners. These outreach events include education or activities around the prioritized health issues identified in the findings from our first formal community health needs assessment in 2009, which include: - Equitable access to health care - Oral Health - Mental Health - Healthy Lifestyles (obesity prevention) - Parenting and Family Support (abuse and neglect prevention) - Injury Prevention - Asthma In FY2022 our community partners and volunteers gave over 4,200 hours of volunteer support to the Center for Children's Health, totaling a value of $130,000. Out of our 812 health outreach events, over 650 were coalition, workgroup, and stakeholder meetings, trainings, and workshops that we led through our collaborations below: - ACEs Task Force - Children's Oral Health Coalition - Lifeguard Your Child (Drowning Prevention Campaign) - Healthy Children Coalition of Parker County - Hood County for Healthy Children - Johnson County Alliance for Healthy Kids - Safe Baby Sleep Council - Safe Kids North Texas - Save a Smile - Wise Coalition for Healthy Children - Wellness Alliance for Total Children's Health of Denton County Selected highlights of our work in FY2022 to improve the health of children and families in the community include: - Over 6,600 children received a limited oral health evaluation and over 1,800 dental procedures were provided to children with dental disease for a total value of $255,000. - Provided over 355 car seat checks to families in need - Provided 452 continued education credits to over 255 community professionals at our mental health education workshops. - Coordinated and engaged 545+ volunteers and collaboration members. - Provided 5,660 support services and over 470 community referrals to families, meeting needs for food, rent and utilities assistance, school supplies, and mental health. - Distributed 514,096 prevention and educational resources at a value of $652,902 to families and community partners. - Supported 358 events coordinated by community partners.

SCHEDULE H, PART VI, LINE 7
STATE FILING OF COMMUNITY BENEFIT REPORT: Texas

Schedule H, Part I, Line 7, Column (F)
"Bad debt expense of $80,633,206 was included on form 990, Part IX, line 25, column (A), but was subtracted from total expense for the calculation of ""percent of total expense"" in this column."

Schedule H, Part I, Line 7
Financial Assistance & Certain Community Benefits at Cost: Line 7a is calculated using worksheet 1 and the cost to charge ratio. Line 7b Medicaid Shortfall is calculated using worksheet 3 and the cost to charge ratio. Lines 7e - i are calculated using the hospital's internal activity reports.

Schedule H, Part I, Line 3C
Cook Children's also uses asset level, medical indigency, insurance status, underinsurance status, and residency in determining eligibility for free or discounted care.

SCHEDULE H, PART VI, LINE 4
Community Information: Cook Children's eight-county service region is based in North Central Texas and comprises Collin, Denton, Grayson, Hood, Johnson, Parker, Tarrant, and Wise Counties. Cook Children's evaluates the statistics describing our community and representing our population served with every Community Health Needs Assessment (CHNA). For Fiscal Year 2022, all information provided is in response to our 2021 CHNA. Furthermore, the statistics described within this section reflect those reported in our 2021 CHNA. Please note: Our 2024 CHNA is currently in development and will be approved and posted by September 30, 2025. The U.S. Census Bureau classifies these counties as follows: Collin County-mostly urban, 5% rural; Denton County-mostly urban, 7% rural; Grayson County-rural 43%; Hood County-mostly urban, 33% rural; Johnson County-mostly urban, 38% rural; Parker County-rural 56%; Tarrant County-mostly urban, 1% rural and Wise County-mostly rural 72% (1). The FWSA total population of 3,309,223 includes 972,470 children from birth to age 17, while the PSA total population of 1,938,813 includes 512,680 children from birth to age 17. Overall, this eight-county region is home to a diverse population of 4,414,214 people, and 1,269,810 (28%) are children 17 years and younger (2). Of those 1,269,810 children ages 0-17, there are 265,400 children living in Collin County; 215,340 in Denton County; 31,940 in Grayson County; 12,230 in Hood County; 145,140 in Johnson County; 36,070 in Parker County; 547,340 in Tarrant County; and 16,350 in Wise County (2). The annual median income for families with children under age 18 range between $63,311 in Grayson County to $117,935 in Collin County (2). Of the 1,269,810 children under age 18 living in the region, nearly 150,000 (12%) live in households with income below the poverty level, and children in households that receive Supplemental Security Income (SSI), cash public assistance or food stamps/SNAP benefits ranges from 8% in Collin County to 27% in Grayson County. Of the 1,269,810 children under age 18 living in the region, between 8%-27% live in households that receive Supplemental Security Income (SSI), cash public assistance, or Food Stamps/SNAP benefits (2). The information below reflects race and ethnicity by county within our region. 2021 U.S. Census Estimates of Race and Ethnicity (Children under 18 years) (2) . Asian: Collin 16.2%; Denton 9.6%; Grayson 1.7%; Hood 0.7%; Johnson 5.2%; Parker 0.7%; Tarrant 5.6%; Wise 0.6% . Black/African American: Collin 10.3%; Denton 9.9%; Grayson 6%; Hood 0.8%; Johnson 4.7%; Parker 1.0%; Tarrant 16.8%; Wise 1.3% . Other Race/Two or More Races: Collin 0.5%; Denton 0.5%; Grayson 0.5%; Hood 1.0%; Johnson 0.2%; Parker 0.5%; Tarrant 0.8%; Wise 0.6% . White: Collin 55.0%; Denton 57.6%; Grayson 74.6%; Hood 84.2%; Johnson 79.3%; Parker 82.6%; Tarrant 45.2%; Wise 76.8% . Hispanic or Latino (Any Race): Collin 15.5%; Denton 19.6%; Grayson 14.2%; Hood 12.4%; Johnson 7.9%; Parker 13.0%; Tarrant 29.5%; Wise 19.3% The Cook Children's eight-county service region contains three medically underserved areas and two medically underserved populations as defined by the Health Resources & Services Administration. These areas are: Medically Underserved Areas (3) . Denton County: Known as Poverty Population by Service Area Name, Medical Underservice Score is 0 (Governor's Exception), Rural Status is Non-Rural . Tarrant County: Known as Diamond Hill Service Area by Service Area Name, Medical Underservice Score is 57.5, Rural Status is Non-Rural . Tarrant County: Known as Fort Worth-North by Service Area Name, Medical Underservice Score is 58, Rural Status is Non-Rural Medically Underserved Population (3) . Grayson County: Known as Low Income-Grayson County by Service Area Name, Medical Underserved Score is 61, Rural Status is Partially Rural . Tarrant County: Known as Low Inc-East Side by Service Area Name, Medical Underserve Score is 59.8, Rural Status is Non-Rural

SCHEDULE H, PART VI, LINE 6
Affiliated Health Care System: Cook Children's also operates seven neighborhood clinics providing primary care to underserved populations around the city's perimeter and inner city to help assure care is provided in the most appropriate setting. Both preventive and therapeutic dental health care are provided to underserved populations. Mental and behavioral health is provided in both inpatient and outpatient settings subsidized by Cook Children's. Cook Children's Health Plan is a contracted intermediary for Medicaid managed care and Chip, providing an open provider panel for all eligible children in the six-county primary service area. Cook Children's Home Health offers pediatric-specific home care to assure care is provided in the most appropriate and lowest cost setting.

Schedule H, Part II, Lines 1-10
"Community Building Activities: Physical Improvements and Housing: Cook Children's is located in the Near South Side of Fort Worth which includes the Medical District as well as a diverse mix of residential neighborhoods. To address neighborhood improvement needs, Cook Children's is a member of Fort Worth South, Inc., a nonprofit organization that partners with the city of Fort Worth and other community organizations to advance educational initiatives, public policies, and community programs that foster a revitalized and safe central city. Strategic planning has resulted in improved security, code enforcement, and transportation for residents and employees who work in the area. Coalition Building: Cook Children's is the lead organization for the Wellness Alliance for Total Children's Health of Denton County (""WATCH""). WATCH of Denton County is a collaboration of both public and private organizations and individuals who are invested in the total wellness of Denton County's children. WATCH currently works to increase awareness of and access to mental health services in Denton County. Cook Children's is also a participant in the Denton County Behavioral Health Leadership Team which advocates and facilitates a collaborative person-centered behavioral health system to repair and restore lives by ensuring behavioral health services are available to meet the needs of all, assessing data for continuous outcome measurements, prioritizing data driven recommendations, and providing a continuum of care in Denton County. Cook Children's is also a participant in the Intellectual and Developmental Disabilities Council of Tarrant County which is a community coalition of providers, public officials, families, and self-advocates who have come together to increase opportunities for people with intellectual disabilities in our community. Community Health Improvement Advocacy: Advocacy efforts by Cook Children's are enhanced through membership in various local, state, and national organizations. Issues addressed include community needs assessment, access to health care and insurance for underserved populations, and advocacy for specific health issues such as child abuse and neglect and preventable injuries. Over 1,000 hours were contributed to multiple coalitions, committees, and councils for FYE 2022."

SCHEDULE H, PART I, LINE 6A & 6B
Cook Children's conducts a CHNA and prepares a summary report every three years. The most recent CHNA was conducted in 2021, and the written CHNA report was posted in 2022. The 2021 CHNA report is available to the public on our website: (https://www.cookchildrens.org/about/community-outreach/community-health-n eeds-assessment/). The next CHNA (2024) is currently in development and will be posted by September 30, 2025.