**U.S. Department of Health and Human Services**

**Health Resources and Services Administration**

*Bureau of Primary Health Care*

*Service Area Competition (including all competing continuations)
Funding for the Health Center Program*

***Service Area Competition -- Additional Service Areas***

*New and Competing Continuations*

*Announcement \# HRSA-08-112 and HRSA-08-113*

**Catalog of Federal Domestic Assistance (CFDA) No. 93.224**

**PROGRAM GUIDANCE**

Fiscal Year 2008

**Application Due Dates in Grants.gov:**

***HRSA-08-112: February 8, 2008***

***HRSA-08-113: February 8, 2008***

**Date of Issuance*: January 8, 2008***

> Nicole Amado
>
> Public Health Analyst
>
> Bureau of Primary Health Care
>
> Office of Policy and Program Development
>
> Telephone: 301/594-4300

Fax: 301/480-7225

Email: namado@hrsa.gov

Technical Assistance Resources:
[www.hrsa.gov/grants/technicalassistance/sac.htm](http://www.hrsa.gov/grants/technicalassistance/sac.htm)

*Authority: Public Health Service Act, Section 330, 42 U.S.C. 254b*

**EXECUTIVE SUMMARY**

This application guidance details the Service Area Competition
(SAC)-Additional Areas eligibility requirements, review criteria and
awarding factors for organizations seeking a grant for operational
support under the Health Center Program authorized by section 330 of the
Public Health Service (PHS) Act as amended. This particular guidance
includes only the following type of health centers: Community Health
Center (CHC) (section 330(e)).

This application guidance details the requirements, review criteria and
awarding factors for organizations seeking operational support through a
SAC-Additional Areas in fiscal year (FY) 2008 and supplements the list
of service areas identified in HRSA 008-007 and HRSA 08-008 previously
released March 22, 2007. **For FY 2008, the following differences should
be noted:**

-   New application due dates have been established.

-   Several review criteria have been revised.

-   **There is a new process for submitting Federal Tort Claims Act
    (FTCA) deeming applications.** Please reference Program Assistance
    Letter 2007-02: Updated Application Submission Instructions for FTCA
    Deeming Under the Federally Supported Health Centers Assistance Act
    for Calendar Year 2008 available at
    <http://bphc.hrsa.gov/policy/pal0702.htm>**.**

-   FORM 1-Part B - BPHC-Funding Request Summary is **NO LONGER**
    required for SAC-Additional Areas applicants.

-   FORM 7 -- Compliance Checklist is **NO LONGER** required for
    SAC-Additional Areas applicants.

-   Instructions for the Budget Presentation are included in Appendix D.

-   Instructions for the Health Care and Business Plans have been
    revised in Appendix E.

-   Application must be submitted electronically through Grants.gov.

-   Directions for electronic submission of the application have been
    updated.

Eligible applicants must be:

1.  Public or nonprofit private entities, including tribal, faith-based
    and community-based organizations; [and]{.underline}

2.  Organizations proposing to serve the same service area and/or
    populations identified in Appendix F. This includes:

-   Grantees whose project period ends on or after October 31, 2007 and
    before October 1, 2008.

-   New organizations that can serve the entire service area and/or
    population identified in Appendix F. New organizations include an
    organization representing a consortium of health centers who through
    their partnership can serve the entire service area and/or
    population.

Competing organizations must:

a.  Provide services to the entire announced service area;

b.  Provide services to the entire population currently being served
    (applicants may not propose to serve only a segment of the existing
    population being served);

c.  Provide the same or comparable comprehensive primary health care
    services presently being provided to the population;

d.  Utilize Federal funding to serve patients previously served by the
    existing grantee and;

e.  Request equal or lesser amount of Federal funding as currently
    received by the existing grantee, including funding for special
    populations (migrant, homeless, and public housing programs).

Note: Organizations previously identified as "new starts" due to their
recent initial funding and whose project period is expiring between
October 31, 2007 and October 1, 2008 are considered existing grantees,
not new organizations, for the purposes of completing the SAC-Additional
Areas application.

Organizations are eligible to apply for areas designated in Appendix F
of this guidance. **All applicants requesting SAC-Additional Areas
funding must use this guidance.** It should be reviewed thoroughly prior
to making a decision to apply. Interested organizations should refer to
Appendix F of this guidance and/or [grants.gov](http://www.grants.gov/)
for further information regarding specific service areas.

All applicants are expected to demonstrate compliance with the
requirements of section 330 of the PHS Act, as amended and applicable
regulations. **Applicants are encouraged to review Appendix I for
additional information on program requirements and expectations.**

HRSA is ***requiring*** applicants for this funding opportunity to apply
electronically through Grants.gov, <http://www.grants.gov/>. All
applicants ***must*** submit in this manner unless the applicant is
granted a written exemption from this requirement in advance by the
Director of HRSA's Division of Grants Policy. Applicants must request an
exemption in writing from <DGPWaivers@hrsa.gov>, and provide details as
to why they are technologically unable to submit electronically though
the Grants.gov portal. Make sure you specify the announcement number for
which you are seeking relief. HRSA and its Grants Application Center
(GAC) will only accept paper applications from applicants that received
prior written approval.

The Grants.gov registration process involves three basic steps:

A.  Register your organization

B.  [Register yourself as an Authorized Organization
    Representative](http://www.grants.gov/applicants/register_aor.jsp)
    (AOR)

C.  [Get authorized as an AOR by your
    organization](http://www.grants.gov/applicants/aor_authorization.jsp)

Please visit the Grants.gov website at
<http://www.grants.gov/applicants/get_registered.jsp> or call the
Grant.gov Contact Center at 1.800.518.4726 between 7am and 9pm ET for
additional technical assistance on the registration process. 

**The registration process can take up to one month.** **Please refer to
Appendix B for information on registering, and Appendix A, Section 3 for
information on applying through Grants.gov.** **If you do not complete
the registration process, you will be unable to submit an application.
Applicants are strongly encouraged to register multiple authorizing
organization representatives.**

**Applications must be submitted by 8:00 P.M. ET by the due date listed.
To ensure that you have adequate time to follow procedures and
successfully submit the application, we recommend that you register
immediately in Grants.gov and complete the forms as soon as possible.**

It is the responsibility of the applicant to ensure that the complete
application is submitted electronically by the published due date and
time. Applications will be considered on time if submitted
electronically by the due date and time, as shown only by the electronic
submission record. Applications which do not meet the criteria above are
considered late applications. Health Resources and Services
Administration (HRSA) shall notify each late applicant that its
application will not be considered in the current competition. Please
indicate that you are responding to HRSA-08-112 or HRSA 08-113:
SAC-Additional Service Areas.

Per section 330(k)(3)(H) of the PHS Act (42 U.S.C. 254b), the health
center governing board must approve the health center's annual budget
and approve applications for subsequent grants for the health center. 
In addition, the SF-424 face page, included in the required PHS 5161
Grant Application and which must be signed by the applicant's authorized
representative (most often the Executive Director, Program Director, or
Board Chair), certifies that all data in the application are true and
correct and that the document has been duly authorized by the governing
body of the applicant.  It also certifies that the applicant will comply
with the attached assurances if the assistance is awarded. Selection of
the responsible person should be consistent with responsibilities
authorized by the organization's bylaws.

**Authorized representatives that sign the SF-424 are reminded that a
copy of the governing board's authorization for them to sign the
application as official representative must be on file in the
applicant's office and that their signature also assures that the
governing board has reviewed and approved ALL content of the
application, including the program specific forms.**

Service areas available in these funding opportunities are listed below.

+-----------------+---------------+-------+------------+-------------+
| **Project       | **Service     | **St  | **Target** | **HRSA      |
| Period Start    | Area City**   | ate** |            | A           |
| Date**          |               |       | **Popul    | nnouncement |
|                 |               |       | ation(s)** | Number**    |
|                 |               |       |            |             |
|                 |               |       | **Served** |             |
+-----------------+---------------+-------+------------+-------------+
| April 1, 2008   | Corbin        | KY    | CHC        | HRSA-08-112 |
+-----------------+---------------+-------+------------+-------------+
| April 1, 2008   | Tylertown     | MS    | CH         | HRSA-08-112 |
+-----------------+---------------+-------+------------+-------------+
| June 1, 2008    | Manson        | NC    | CH         | HRSA 08-113 |
+-----------------+---------------+-------+------------+-------------+

For your convenience, application deadlines for projects ending in FY
2008 are provided below. Please review the HRSA Preview or Grants.gov
for more current information.

  -------------------- ----------------- ---------------------------------
  **Project Period     **HRSA            **Grants.gov Application
  Start Date**         Announcement      Deadline**
                       Number**          

  April 1, 2008        HRSA 08-112       February 8, 2008 at 8:00 PM ET

  June 1, 2008         HRSA-08-113       February 8, 2008 at 8:00 PM ET
  -------------------- ----------------- ---------------------------------

If you have questions regarding the FY 2008 Service Area
Competition-Additional Areas application and/or the review process
described in this application guidance, please call Nicole Amado in the
Bureau of Primary Health Care's Office of Policy and Program Development
at 301-594-4300 or namado@hrsa.gov.

**Guidance Table of Contents**

[I. Funding Opportunity Description 8](#__RefHeading___Toc151519201)
[**Purpose** 8](#__RefHeading___Toc151519202)

[**Background** 8](#__RefHeading___Toc151519203)

[II. Award Information 9](#__RefHeading___Toc151519205)

[**1. Type of Award** 9](#__RefHeading___Toc151519206)

[**2. Summary of Funding** 9](#Award_summary)

[III. Eligibility Information 10](#__RefHeading___Toc151519209)

[**1. Eligible Applicants** 10](#Eligibility_who)

[**2. Cost Sharing/Matching** 11](#__RefHeading___Toc151519211)

[**3. Other** 11](#__RefHeading___Toc151519212)

[IV. Application and Submission Information
11](#__RefHeading___Toc151519213)

[**1. Address to Request Application Package**
11](#__RefHeading___Toc151519214)

[**Application Materials** 11](#__RefHeading___Toc151519215)

[**2. Content and Form of Application Submission**
12](#__RefHeading___Toc151519216)

[**Application Format Requirements**
12](#Application_formatrequirements)

[**Application Format** 17](#__RefHeading___Toc151519218)

[**i. Application Face Page** 17](#__RefHeading___Toc151519219)

[**ii. Table of Contents** 17](#__RefHeading___Toc151519220)

[**iii. PHS 5161-1 HHS Checklist** 18](#__RefHeading___Toc151519221)

[**iv. Budget** 18](#__RefHeading___Toc151519222)

[**v. Budget Justification** 18](#__RefHeading___Toc151519223)

[**vi. Staffing Plan and Personnel Requirements**
20](#__RefHeading___Toc151519224)

[**vii. Assurances** 21](#__RefHeading___Toc151519225)

[**viii.** **Certifications** 21](#__RefHeading___Toc151519226)

[**ix. Project Abstract** 21](#__RefHeading___Toc151519227)

[**x.** **Program Narrative** 22](#__RefHeading___Toc151519228)

[**xi.** **Program Specific Forms** 23](#__RefHeading___Toc151519229)

[**xii.** **Attachments** 23](#__RefHeading___Toc151519231)

[**3. Submission Dates and Times** 27](#__RefHeading___Toc151519232)

[**4. Intergovernmental Review** 28](#__RefHeading___Toc151519235)

[**5. Funding Restrictions** 29](#Application_fundingrestrictions)

[**6. Other Submission Requirements** 29](#__RefHeading___Toc151519237)

[V. Application Review Information 31](#__RefHeading___Toc151519238)

[**1. Review Criteria** 31](#__RefHeading___Toc151519239)

[**2. Review and Selection Process** 43](#__RefHeading___Toc151519245)

[**3. Anticipated Announcement and Award Dates**
44](#Review_FundingPriority)

[VI. Award Administration Information 44](#__RefHeading___Toc151519248)

[**1. Award Notices** 44](#__RefHeading___Toc151519249)

[**2. Administrative and National Policy Requirements**
44](#__RefHeading___Toc151519250)

[**3. Reporting** 45](#__RefHeading___Toc151519253)

[VII. Agency Contacts 46](#__RefHeading___Toc151519254)

[VIII. Other Information 47](#__RefHeading___Toc151519255)

[IX. Tips for Writing a Strong Application
48](#__RefHeading___Toc151519258)

[APPENDIX A: HRSA's Electronic Submission User Guide
49](#appendix-a-hrsas-electronic-submission-user-guide)

[Appendix B: Registering and Applying Through Grants.gov
64](#appendix-b-registering-and-applying-through-grants.gov)

[APPENDIX C:](#appendix-c) [PROGRAM SPECIFIC FORMS WITH INSTRUCTIONS
69](#program-specific-forms-with-instructions)

[APPENDIX D](#__RefHeading___Toc151519314): [INSTRUCTIONS FOR THE BUDGET
PRESENTATION 93](#instructions-for-the-budget-presentation)

[APPENDIX E](#appendix-e): [INSTRUCTIONS FOR THE HEALTH CARE PLAN AND
BUSINESS PLAN
101](#instructions-for-the-health-care-plan-and-business-plan)

[APPENDIX F:](#appendix-f) [FY 2008 SERVICE AREAS
106](#fy-2008-service-areas)

[APPENDIX G:](#appendix-g) [PRIMARY CARE
ASSOCIATION,](#primary-care-association) [PRIMARY CARE OFFICE AND
108](#primary-care-office-and)

[NATIONAL ORGANIZATION CONTACTS 108](#national-organization-contacts)

[APPENDIX H:](#appendix-h) [SERVICE AREA COMPETITION DEFINITIONS
116](#service-area-competition-definitions)

[APPENDIX I:](#appendix-i) [Summary of Program requirements and
expectations 122](#summary-of-program-requirements-and-expectations)

**PUBLIC BURDEN STATEMENT:** An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless
it displays a currently valid OMB control number. The OMB control number
for this project is 285. Public reporting burden for the applicant for
this collection of information is estimated to average 100 hours,
including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 14-45, Rockville, Maryland,
20857.

[]{#__RefHeading___Toc151519201 .anchor}**I. Funding Opportunity
Description**

[]{#__RefHeading___Toc151519202 .anchor}**Purpose**

> The Health Resources and Services Administration administers the
> Health Center Program, as authorized by section 330 of the Public
> Health Service (PHS) Act, 42 U.S.C. 254b, as amended. The Health
> Center Program promotes the development and operation of
> community-based primary health care service systems in medically
> underserved areas and improves the health status of medically
> underserved populations. This application guidance details the Service
> Area Competition (SAC) Additional Areas eligibility requirements,
> review criteria and awarding factors for organizations seeking a grant
> for operational support under the Health Center Program including:
> Community Health Center (CHC) (section 330(e)) authorized under the
> PHS Act, as amended. This application guidance supplements the list of
> service areas identified in the FY08 Service Area Competitions
> previously released March 22, 2007.
>
> The SAC-Additional Areas application is a request for financial
> assistance to provide comprehensive primary care services to an
> underserved area or population that has been competitively announced
> in Appendix F of this guidance, the HRSA Preview and/or website,
> and/or Grants.gov.
>
> Eligible applicants must be public or nonprofit private entities which
> can include tribal, faith-based and community-based organizations.
> Applicants are not required to be operational at the time of
> application but must provide the same or comparable comprehensive
> primary health care services presently being provided to the
> population within 120 days of grant award. Applicants are also not
> required to be current recipients of section 330 funding. 
>
> All applicants are expected to demonstrate compliance with the
> requirements of section 330 of the PHS Act, as amended and applicable
> regulations and guidances. Applicants are encouraged to review
> Appendix I for additional information on program requirements and
> expectations.
>
> Interested organizations should refer to Appendix F of this guidance,
> the HRSA Preview and/or website, and/or Grants.gov for further
> information regarding specific service areas and deadlines.

[]{#__RefHeading___Toc151519203 .anchor}**Background**

> The mission of HRSA is to provide national leadership, program
> resources, and services needed to improve access to culturally
> competent, quality health care. In particular, HRSA works to assure
> the availability of quality health care to low-income, uninsured,
> isolated, vulnerable, and special needs populations and to meet the
> unique health care needs of these populations. HRSA is committed to
> the goal of improving and expanding access to health care for all
> Americans nationwide, including the estimated 45 million uninsured and
> the more than 50 million individuals living in federally designated
> medically underserved areas that lack access to affordable,
> appropriate primary and preventive health care.
>
> Individually, each health center plays an important role in the goal
> of ensuring access to services and combined they have had a critical
> impact on the health care status of medically underserved and
> vulnerable populations throughout the United States. At the end of the
> 2005 calendar year, there were more than 950 federally-funded health
> centers with more than 3,745 primary care delivery sites located in
> urban and rural underserved areas throughout the U.S. and its
> territories. Over 14 million medically underserved and uninsured
> patients received high quality, cost-effective, culturally
> appropriate, accessible and affordable preventive and primary health
> care services through the federally-supported Health Center Program.
>
> It is the intent of HRSA to continue to support health services in
> these underserved areas, given the unmet need inherent in the
> provision of services to medically underserved populations. Health
> centers must make services available and accessible promptly, and in
> such a manner which will assure continuity of service to the
> individuals in the service area. It is expected that each
> SAC-Additional Areas application submitted to serve one of these areas
> and/or populations will present a clear focus on maintaining access to
> care and reducing health disparities identified in the same target
> population(s) that is currently being served by the existing grantee.

**Specific Requirements/Expectations**

### All applicants are expected to demonstrate compliance with the applicable requirements of section 330 of the PHS Act, and guidelines, including the PIN 98-23: Health Center Program Expectations available at [**www.bphc.hrsa.gov/pinspals/pinsarchive.htm**](http://www.bphc.hrsa.gov/pinspals/pinsarchive.htm). In addition to these general requirements, there are specific requirements and expectations for applicants requesting funding for community health centers authorized under section 330. Failure to document and demonstrate compliance in the application will significantly reduce the likelihood of approval and funding. Applicants are encouraged to review Appendix I for additional information on program requirements and expectations. 

> COMMUNITY HEALTH CENTER (CHC) APPLICANTS (section 330(e)):
>
> CHC applicants must demonstrate in their proposal how they will
> maintain access to comprehensive primary and preventive health care
> and improve the health status of underserved and vulnerable
> populations in the area to be served. Applicants are also expected to
> demonstrate that the proposal will address the major health care needs
> of the target population and will ensure the availability and
> accessibility of essential primary and preventive health services,
> including oral health, mental health and substance abuse services, to
> all individuals in the service area. Applicants are expected to
> demonstrate compliance with section 330(e) and all applicable
> regulations and guidelines.

[]{#__RefHeading___Toc151519205 .anchor}**II. Award Information**

[]{#__RefHeading___Toc151519206 .anchor}**1. Type of Award**

Funding will be provided in the form of a grant.

[]{#Award_summary .anchor}

**2. Summary of Funding**

> It is expected that the request for Federal support will not exceed in
> any year of the proposed project period, the annual level of Federal
> section 330 funding that is currently provided to the area and/or
> population. It is also expected that the budgets presented in the
> application will be reasonable and appropriate based on the services
> provided and the number and type (i.e., uninsured, homeless, migrant,
> public housing residents, low income children and adolescents, etc.)
> of individuals to be served. Applicants should propose up to a 5 year
> project period. The budgets (see Sample Budget Presentation in
> Appendix D for more information) should be consistent with the health
> care and business plans presented in the application, as well as the
> proposed project period.
>
> HRSA will provide funding during Federal fiscal year 2008.
> Approximately \$2,700,000 is expected to be available to fund three
> SAC-Additional Areas awards. Funding beyond the first year is
> dependent on the availability of appropriated funds for the Health
> Center Program, grantee satisfactory performance, and a determination
> that continued funding is in the best interest of the government.
>
> Federal funding levels awarded and the length of project period may be
> adjusted based on an analysis of the organization's performance and
> experience related to operating costs, utilization, provider staffing
> and revenue generation. Approved applicants will not be funded at
> levels greater than the currently approved base level of funding for
> the announced underserved area or population. See Section iv. Budget
> of this application guidance for further information and instruction
> on the development of the application budget. Federal funding levels
> for newly funded applicants may also be adjusted based on an analysis
> of the budget and cost factors.
>
> For additional information regarding the current level of targeted
> support for a specified community or population, please contact Nicole
> Amado with the **Office of Policy and Program Development, Bureau of
> Primary Health Care at (301) 594-4300 or namado@hrsa.gov**.

[]{#__RefHeading___Toc151519209 .anchor}**III. Eligibility
Information**[]{#Eligibility_who .anchor}

**1. Eligible Applicants**

> Eligible applicants must be:

1.  Public or nonprofit private entities, including tribal, faith-based
    and community-based organizations; [and]{.underline}

2.  Organizations proposing to serve the same service area and/or
    populations identified in Appendix F. This includes:

-   Grantees whose project period ends on or after October 31, 2007 and
    before October 1, 2008.

-   New organizations that can serve the entire service area and/or
    population identified in Appendix F. New organizations include an
    organization representing a consortium of health centers who through
    their partnership can serve the entire service area and/or
    population.

> Competing organizations must:

a.  Provide services to the entire announced service area;

b.  Provide services to the entire population currently being served
    (applicants may not propose to serve only a segment of the existing
    population being served);

c.  Provide the same or comparable comprehensive primary health care
    services presently being provided to the population;

d.  Accept new patients in addition to their existing patient case load
    (if applicable) to ensure that section 330 grant funds do not
    supplant the applicant's current level of effort; and

e.  Request equal or lesser amount of Federal funding as currently
    received by the existing grantee, including funding for special
    populations (migrant, homeless, and public housing programs).

> All applicants are expected to demonstrate compliance with the
> requirements of section 330 of the PHS Act as amended, and applicable
> regulations. Applicants are encouraged to review Appendix I for
> additional information on program requirements and expectations.
>
> Interested organizations should refer to Appendix F of this guidance,
> the HRSA Preview and/or website, and/or
> [Grants.gov](http://www.grants.gov/) [FIND]{.underline} for further
> information regarding specific areas and deadlines. **Applications
> that do not meet the eligibility requirements will be considered
> non-responsive and will not be considered for funding under this
> announcement.**

[]{#__RefHeading___Toc151519211 .anchor}**2. Cost Sharing/Matching**

> Cost sharing or matching is not a requirement for this funding
> opportunity.  As required by 42 CFR 51c.305, HRSA will take into
> consideration whether and to what extent an applicant plans to
> maximize all sources of revenue through an appropriate and reasonable
> budget which includes non-grant resources to support the proposed
> project.  Please see Section IV.2.iv Budget for clarification and
> guidelines pertaining to the budget presentation. 

[]{#__RefHeading___Toc151519212 .anchor}**3. Other**

> Any application that fails to satisfy the deadline requirements
> referenced in Section IV.3. Submission Dates and Times will be
> considered non-responsive and will not be considered for funding under
> this announcement.
>
> Applicants currently receiving section 330 funding and applying to
> serve their current service area should ensure that their application
> reflects their current approved scope of project. Any proposed changes
> in scope requiring prior approval MUST be submitted under separate
> cover. The change in scope application must be emailed to
> <bphcscope@hrsa.gov> and a signed original must be sent to the HRSA's
> Division of Grants Management Operations with a courtesy copy to the
> Project Officer. Please refer to the most recent guidance on this
> subject contained in PIN 2002-07: Scope of Project Policy (available
> onsite at [www.bphc.hrsa.gov](http://www.bphc.hrsa.gov/)), or contact
> <BPHCscope@hrsa.gov> for more information.

[]{#__RefHeading___Toc151519213 .anchor}**IV. Application and Submission
Information**

1.  []{#__RefHeading___Toc151519214 .anchor}**Address to Request
    Application Package**

    []{#__RefHeading___Toc151519215 .anchor}**Application Materials**

> HRSA is ***requiring*** applicants for this funding opportunity to
> apply electronically through Grants.gov, http://www.grants.gov. All
> applicants ***must*** submit in this manner unless the applicant is
> granted a written exemption from this requirement in advance by the
> Director of HRSA's Division of Grants Policy. Applicants must request
> an exemption in writing from
> [DGPWaivers@hrsa.gov](mailto:DGPClearances@hrsa.gov), and provide
> details as to why they are technologically unable to submit
> electronically though the Grants.gov portal. Make sure you specify the
> announcement number for which you are seeking relief. **HRSA and its
> Grants Application Center (GAC) will only accept paper applications
> from applicants that received prior written approval. Applicants
> technologically unable to scan the signed face sheet should also
> contact the DGPWaivers mailbox to provide information and request
> further instructions. However, the application must still be submitted
> under the appropriate deadline.**
>
> Refer to Appendix A for detailed application and submission
> instructions. Pay particular attention to Section 3, which provides
> detailed information on the competitive application and submission
> process.
>
> Applicants must submit proposals according to the instructions in
> Appendix A, using this guidance in conjunction with Public Health
> Service (PHS) Application Form 5161-1. These forms contain additional
> general information and instructions for grant applications, proposal
> narratives and budgets. These forms may be obtained from the following
> sites by:

(1) Downloading from <http://www.hrsa.gov/grants/forms.htm>

> \(2\) Contacting the HRSA Grants Application Center at:
>
> The Legin Group, Inc.

910 Clopper Road, Suite 155 South

Gaithersburg, MD 20878

> Telephone: 877-477-2123
>
> <HRSAGAC@hrsa.gov>
>
> Instructions for preparing portions of the application that must
> accompany Application Form 5161-1 appear in the "Application Format"
> section below.

[]{#__RefHeading___Toc151519216 .anchor}**2. Content and Form of
Application Submission**

[]{#Application_formatrequirements .anchor}**Application Format
Requirements**

> See Appendix A, Section 4 for detailed application submission
> instructions. These instructions must be followed.
>
> **The total size of all uploaded files may not exceed the equivalent
> of 150 pages when printed by HRSA**. All non-compliant applications
> that exceed the page limit will be returned to the applicant without
> further consideration.
>
> This page limit does not include the program specific forms
> (identified as Attachment #2) or the financial audit (identified as
> Attachment #9). The page limit also does not include the Application
> for Federal Assistance (SF 424), Grants.gov Lobbying Form, Budget
> Information for Non-Construction Program (SF-424A), HHS Checklist
> (Form 5161-1), Assurances, and Certifications.
>
> **Please note that the page limit [does]{.underline} include the
> project abstract, program narrative, budget justification, attachments
> #3 -- #15, and the Health Care and Business Plan Tables.**
>
> Applications that exceed the specified limits (approximately 20 MB, or
> that exceed 150 pages when printed by HRSA) will be deemed
> non-responsive and will not be considered for funding under this
> announcement. In cases where the uploaded attachment exceeds 20 MB,
> HRSA will make a determination based on the number of printed pages.
> All non-compliant applications will be returned to the applicant
> without further consideration.
>
> Per section 330(k)(3)(H) of the PHS Act (42 U.S.C. 254b), the health
> center governing board must approve the health center's annual budget
> and approve applications for subsequent grants for the health center. 
> In addition, the SF-424 face page, included in the required PHS 5161
> Grant Application and which must be signed by the applicant's
> authorized representative (most often the Executive Director, Program
> Director, or Board Chair), certifies that all data in the application
> are true and correct and that the document has been duly authorized by
> the governing body of the applicant.  It also certifies that the
> applicant will comply with the attached assurances if the assistance
> is awarded. Selection of the responsible person should be consistent
> with responsibilities authorized by the organization's bylaws.
>
> **Authorized representatives that sign the SF-424 are reminded that a
> copy of the governing board's authorization for them to sign this
> application as official representative must be on file in the
> applicant's office and that their signature also assures that the
> governing board has reviewed and approved ALL content of the
> application, including the program specific forms.**
>
> **Application Format**
>
> Applications for funding must consist of the following documents in
> the following order:

### SF 424 Non Construction -- Table of Contents

-   It is mandatory to follow the instructions provided in this section
    to ensure that your application can be printed efficiently and
    consistently for review.

-   Failure to follow the instructions may make your application
    non-compliant. Non-compliant applications will not be given any
    consideration and those particular applicants will be notified.

-   For electronic submissions, applicants only have to number the
    electronic attachment pages sequentially, resetting the numbering
    for each attachment, i.e., start at page 1 for each attachment. Do
    not attempt to number standard OMB approved form pages.

-   For electronic submissions no table of contents is required for the
    entire application. HRSA will construct an electronic table of
    contents in the order specified.

-   When providing any electronic attachment with several pages, add
    table of content page specific to the attachment. Such page will not
    be counted towards the page limit.

-   For paper submissions (when allowed), number each section
    sequentially, resetting the page number for each section. i.e.,
    start at page 1 for each section. Do not attempt to number standard
    OMB approved form pages.

-   For paper submissions ensure that the order of the forms and
    attachments is as specified below.

+------------------+------+-----------------------+-------------------+
| **Grants.gov     | **   | **Instruction**       | **HRSA/Program    |
| Application      | Form |                       | Guidelines**      |
| Section**        | Ty   |                       |                   |
|                  | pe** |                       |                   |
+==================+======+=======================+===================+
| Application for  | Form | Pages 1, 2 & 3 of the | Not counted in    |
| Federal          |      | SF-424 face page.     | the page limit    |
| Assistance       |      |                       |                   |
|                  |      |                       |                   |
| (SF-424)         |      |                       |                   |
+------------------+------+-----------------------+-------------------+
| Project          | At   | Upload the project    | Required          |
| Summary/Abstract | tach | abstract on page 2 of | attachment.       |
|                  | ment | SF-424 - Box 15       | Counted in the    |
|                  |      |                       | page limit. Refer |
|                  |      |                       | to guidance for   |
|                  |      |                       | detailed          |
|                  |      |                       | instructions.     |
+------------------+------+-----------------------+-------------------+
| Grants.gov       | Form | Required              | Not counted in    |
| Lobbying Form    |      | Certification         | the page limit.   |
|                  |      | Regarding Lobbying.   |                   |
+------------------+------+-----------------------+-------------------+
| Budget Narrative | Form | Supports the upload   | Open form and     |
| Attachment Form  | /    | (attachment) of the   | attach the        |
|                  | At   | Budget Justification  | **Budget          |
|                  | tach | document.             | Justification.**  |
|                  | ment |                       | The uploaded      |
|                  |      |                       | attachment is     |
|                  |      |                       | counted in the    |
|                  |      |                       | page limit. Refer |
|                  |      |                       | to guidance for   |
|                  |      |                       | detailed          |
|                  |      |                       | instructions.     |
+------------------+------+-----------------------+-------------------+
| Project          | Form | Supports the upload   | Open form and     |
| Narrative        | /    | (attachment) of the   | attach the        |
| Attachment Form  | At   | Project Narrative     | **Program         |
|                  | tach | document.             | Narrative.** The  |
|                  | ment |                       | uploaded          |
|                  |      |                       | attachment is     |
|                  |      |                       | counted in the    |
|                  |      |                       | page limit.       |
|                  |      |                       | Please number     |
|                  |      |                       | each page of the  |
|                  |      |                       | project narrative |
|                  |      |                       | in sequential     |
|                  |      |                       | order. Refer to   |
|                  |      |                       | guidance for      |
|                  |      |                       | detailed          |
|                  |      |                       | instructions.     |
|                  |      |                       | Provide table of  |
|                  |      |                       | contents specific |
|                  |      |                       | to this document  |
|                  |      |                       | only as the first |
|                  |      |                       | page (the         |
|                  |      |                       | attachment form   |
|                  |      |                       | and table of      |
|                  |      |                       | contents will not |
|                  |      |                       | be counted in the |
|                  |      |                       | page limit).      |
+------------------+------+-----------------------+-------------------+
| Budget           | Form | Pages 1 & 2 budget    | Not counted in    |
| Information for  |      | for the request of    | the page limit.   |
| Non-Construction |      | Non construction      |                   |
| Programs         |      | related funds.        |                   |
| (SF-424A)        |      |                       |                   |
+------------------+------+-----------------------+-------------------+
| HHS Checklist    | Form | Pages 1 & 2 of the    | Not counted in    |
| Form PHS-5161    |      | HHS checklist.        | the page limit.   |
+------------------+------+-----------------------+-------------------+
| Assurances for   | Form | Supports assurances   | Not counted in    |
| Non-Construction |      | for non construction  | the page limit.   |
| Programs         |      | programs.             |                   |
| (SF-424B)        |      |                       |                   |
+------------------+------+-----------------------+-------------------+
| Disclosure of    | Form | Supports structured   | Not counted in    |
| Lobbying         |      | data for lobbying     | the page limit.   |
| Activities       |      | activities, should be | If the form is    |
|                  |      | completed if          | not applicable,   |
| (SF-LLL)         |      | applicable per the    | there is no need  |
|                  |      | instructions in the   | to complete this  |
|                  |      | Grants.gov Lobbying   | form.             |
|                  |      | Form.                 |                   |
+------------------+------+-----------------------+-------------------+
| Attachments Form | Form | Supports the upload   | See following     |
|                  | /    | (attachment) of the   | attachment table  |
|                  | Att  | 15 numbered           | for specific      |
|                  | achm | attachments. This     | sequence and      |
|                  | ents | form only contains    | instructions.     |
|                  |      | the attachment list.  | Please number     |
|                  |      |                       | each page of the  |
|                  |      |                       | attachments in    |
|                  |      |                       | sequential order  |
|                  |      |                       | beginning with    |
|                  |      |                       | the first page of |
|                  |      |                       | attachment 3. All |
|                  |      |                       | uploaded          |
|                  |      |                       | attachments ARE   |
|                  |      |                       | counted in the    |
|                  |      |                       | page limit        |
|                  |      |                       | **[EXCEPT         |
|                  |      |                       | ATTACHMENT 2:     |
|                  |      |                       | Program Specific  |
|                  |      |                       | Forms and         |
|                  |      |                       | ATTACHMENT 9:     |
|                  |      |                       | Financial         |
|                  |      |                       | Audi              |
|                  |      |                       | t.]{.underline}** |
|                  |      |                       | All attachments   |
|                  |      |                       | are required,     |
|                  |      |                       | unless otherwise  |
|                  |      |                       | specified below.  |
+------------------+------+-----------------------+-------------------+

-   To ensure that attachments are organized and printed in a consistent
    manner, follow the order provided below. Note that these
    instructions may vary across programs.

-   Evidence of Non Profit status and invention related documents, if
    applicable, must be provided in the other attachment form.

-   Additional supporting documents, if applicable, can be provided
    using the available rows. Do not use the rows assigned to a specific
    purpose in the program guidance.

  -----------------------------------------------------------------------
  **Attachment     **Attachment Description (Program Guidelines)**
  Number**         
  ---------------- ------------------------------------------------------
  Attachment 1     Copy of Signed SF-424/5161 Face Sheet. **Not counted
                   in page limit.**

  Attachment 2     Program Specific Forms 1 through 9 (See section xi for
                   detailed information) **Not counted in page limit.**

  Attachment 3     Service Area Map (Required). Counted in page limit.

  Attachment 4     Corporate Bylaws, Signed and Dated (Required). Counted
                   in page limit

  Attachment 5     Project Organizational Chart and Position Descriptions
                   for Key Management Staff (Required). Counted in page
                   limit.

  Attachment 6     Biographical Sketches of Key Management Staff
                   (Required). Counted in page limit.

  Attachment 7     Co-Applicant Agreement (Required for Public Entity
                   Applicants that have a co-applicant board). Counted in
                   page limit

  Attachment 8     Summary of Contracts, Agreements and Subrecipient
                   Arrangements (As applicable). Counted in page limit

  Attachment 9     Most recent independent financial audit (Required).
                   NOT counted in page limit

  Attachment 10    Articles of Incorporation -- Signed Seal Page
                   (Required). Counted in page limit

  Attachment 11    Letters of Support (Required). Counted in page limit

  Attachment 12    Discount Sliding Fee Schedule (Required). Counted in
                   page limit

  Attachment 13    Other Relevant Documents (As applicable). Counted in
                   page limit

  Attachment 14    Health Care Plan and Business Plan Tables (Required).
                   Counted in page limit

  Attachment 15    Evidence of Non-Profit Status (Only applicable for
                   organizations that DO NOT already have current
                   evidence of non-profit status on file with an agency
                   of HHS). Counted in page limit
  -----------------------------------------------------------------------

[]{#__RefHeading___Toc151519218 .anchor}**Application Format**

i.  []{#__RefHeading___Toc151519219 .anchor}***Application Face Page***

> Prepare Public Health Service (PHS) Application Form 5161-1 (SF 424)
> (provided with the application package) according to instructions
> provided in the form itself. For information pertaining to the Catalog
> of Federal Domestic Assistance, the Catalog of Federal Domestic
> Assistance Number is 93.224.

Please be sure to complete the PHS 5161-1, Form 424 Face Page as
follows:

-   *Box 4: Applicant Identifier:* Not applicable-leave blank.

-   *Box 5a. Federal Entity Identifier: * Leave blank. For HRSA-use
    only.

-   *Box 5b. Federal Award Identifier:*  10-digit grant number (H80...)
    found in box 4b from the most recent Notice of Grant Award for
    applicants currently receiving section 330 funds and applying to
    serve their current service area. All other applicants may leave
    this blank.

-   *Box 8c.* Applicant organization's DUNS number

-   *Box 15 Descriptive Title of Applicant's Project:*  Type the title
    of the funding opportunity and upload the Project Abstract here. 

-   *Box 17 Proposed Project Start and End Date:* Provide the start and
    end dates for the proposed project period (up to 5 years). For
    applicant's currently receiving section 330 funds and applying to
    serve their current service area, the proposed start date should be
    consistent with the project period end date noted on the most recent
    Notice of Grant Award.

-   *Box 18: Estimated Funding:* Complete the required information based
    on the funding request for the first year of the project period.
    This information should be consistent with the total provided in the
    applicant's SF-424A Budget for Non-Construction Programs.

> **For more information on completing each section of the SF-424 Face
> Page, activate the "Help Mode" function available at top of the
> electronic form.**
>
> **DUNS Number**
>
> All applicant organizations are required to have a Data Universal
> Numbering System (DUNS) number in order to apply for a grant from the
> Federal Government. The DUNS number is a unique nine-character
> identification number provided by the commercial company, Dun and
> Bradstreet. There is no charge to obtain a DUNS number. Information
> about obtaining a DUNS number can be found at
> <http://www.hrsa.gov/grants/dunsccr.htm> or call 1-866-705-5711.
> Please include the DUNS number in item 8c on the application face
> page. Applications ***will not*** be reviewed without a DUNS number.
>
> Additionally, the applicant organization is required to register with
> the Federal Government's Central Contractor Registry (CCR) in order to
> do electronic business with the Federal Government. Information about
> registering with the CCR can be found at
> [http://www.hrsa.gov/grants/dunsccr.htm](http://www.hrsa.gov/grants/ccr.htm).

ii. []{#__RefHeading___Toc151519220 .anchor}***Table of Contents***

> The application should be presented in the order of the Table of
> Contents provided in Section IV: Application and Submission
> Information of the SAC-Additional Areas guidance. Again, for
> electronic applications no table of contents is necessary, as it will
> be generated by the system. (Note: the Table of Contents will not be
> counted in the page limit).

iii. []{#__RefHeading___Toc151519221 .anchor}***PHS 5161-1 HHS
     Checklist***

> Complete the PHS 5161-1 HHS Checklist accessible from the Grants.gov
> application package under "Mandatory Documents."

iv. []{#__RefHeading___Toc151519222 .anchor}***Budget***

> A complete budget presentation will include the following items:

-   **PHS Form 5161-1, Standard Form 424A-Budget Information for
    Non-Construction Programs:** Use the SF-424A (included as part of
    the Grants.Gov electronic application). and complete sections A and
    B for the first year of the proposed project period and complete
    section E for the remaining years (year 2 through 5) of the proposed
    project period. [Complete section F only if applicable.]{.underline}
    See instructions in Appendix D for further details on completing the
    SF-424A.

-   **Budget Justification:** A detailed budget justification in
    line-item form must be completed for each 12-month period requested
    for Federal funding**.** Applicants may request up to a 5- year
    project period. **Only the first year of the budget justification
    should itemize revenues and expenses for each type of health center
    program (Community: CHC, Migrant: MHC, Homeless: HCH, and/or Public
    Housing: PHPC).** The budget justification should use the budget
    categories found in Section B of the SF-424A and provide sufficient
    detail to explain the amounts requested at one-step below the object
    class category level for the first year. Please see sample budget
    justification in Appendix D for further details. Attach the budget
    justification in the "Budget Narrative Attachment Form" section of
    the Grants.Gov electronic application.

-   **Form 2 - Staffing Profile:** This form (included in the Program
    Specific Forms) must be completed for the first year of the proposed
    project. The amount for total salaries in the last column of the
    Staffing Profile should equal the amount allocated under the
    "Personnel" category of the SF-424A, Section B and should be
    consistent with the amounts included in the detailed budget
    justification as well. Please see Appendix C for instructions on
    completing the Staffing Profile and upload this form together with
    all other Program Specific Forms in Attachment 2.

-   **Form 3 - Income Analysis Form:** This form (included in the
    Program Specific Forms) must be completed for the first year of the
    proposed project. Please see Appendix C for instructions on
    completing the Income Analysis and upload this form together with
    all other Program Specific Forms in Attachment 2.

> Applicants should note that in the formulation of their budget
> presentation, per section 330(e)(5)(A) of the PHS Act (42 U.S.C.
> 254b), the amount of grant funds made in any fiscal year may not
> exceed the amount by which the costs of operation of the center in
> such fiscal year exceed the total of: State, local, and other
> operational funding provided to the center; and the fees, premiums,
> and third-party reimbursements, which the center may reasonably be
> expected to receive for its operations in such fiscal year.

v.  []{#__RefHeading___Toc151519223 .anchor}***Budget Justification***

> Provide a justification in line-item budget form that explains the
> amounts requested for each line in the budget. The budget
> justification should specifically describe how each item will support
> the achievement of proposed objectives. The budget period is for ONE
> year. However, the applicant must submit one-year budgets for each
> subsequent project period years (up to 5 years) at the time of
> application and will also be expected to provide one-year budget with
> each subsequent non-competing continuation application. Line item
> information must be provided to explain the costs entered in the PHS
> 5161-1, Standard Form 424A - Budget Information: Non-Construction
> Programs. **The budget justification must clearly describe each cost
> element and explain how each cost contributes to meeting the project's
> objectives/goals.** Be very careful about showing how each item in the
> "other" category is justified. The budget justification MUST be
> concise. Do NOT use the justification to expand the project narrative.
> In addition, please review the sample budget justification in Appendix
> D.
>
> ***Budget for Multi-Year Grant Award***
>
> Awards, on a competitive basis, will be for a one‑year budget period,
> although project periods may be up to 5 years. Applications for
> continuation grants funded under these awards beyond the initial
> one-year budget period, but within the approved project period, will
> be entertained in subsequent years on a noncompetitive basis, subject
> to availability of funds, satisfactory progress of the grantee and a
> determination that continued funding would be in the best interest of
> the Federal Government.
>
>  
>
> The following guidelines should be used by the applicant in the
> development of the budget justification.
>
> **Personnel Costs:** Personnel costs (salaries and wages) should be
> explained by listing key management staff and all other FTEs who will
> be supported from funds, position title, percent full time
> equivalency, annual salary, and the exact amount requested for each
> year. *Please reference "Form 2: Staffing Profile" as justification
> for dollar figures.*
>
> **Fringe Benefits:** List the components that comprise the fringe
> benefit rate, for example health insurance, taxes, unemployment
> insurance, life insurance, retirement plan, tuition reimbursement. The
> fringe benefits should be directly proportional to that portion of
> personnel costs that are allocated for the project.
>
> **Equipment:** "Equipment\" is defined as an article of nonexpendable,
> tangible personal property having a useful life of more than one year
> and an acquisition cost, which equals or exceeds the lesser of (a) the
> capitalization level established by the organization for the financial
> statement purposes, or (b) \$5,000. Identify each piece of equipment
> that meets this definition and identify the cost per item. Also,
> provide a justification to explain why the item(s) are needed for this
> project. If your organization's capitalization level is lower than the
> Federal amount of \$5,000 per item please submit a statement to
> explain. Please note that most technological purchases and furniture
> items will be identified under the "Supplies" line item because of the
> Federal dollar limitation.
>
> **Supplies:** List the items that the project will use. In this
> category, separate office supplies from medical and educational (e.g.,
> continuing medical education) purchases. Office supplies could include
> paper, pencils, and the like; medical supplies are syringes, blood
> tubes, plastic gloves, etc., and educational supplies may be pamphlets
> and educational videotapes. Remember, they must be listed separately.
>
> **Travel:** List travel costs according to local and long distance
> travel. For local travel, the mileage rate, number of miles, reason
> for travel and staff member/consumers/board members completing the
> travel should be outlined. The budget should also reflect the travel
> expenses associated with participating in meetings and other proposed
> trainings or workshops.
>
> **Other:** Put all costs that do not fit into any other category into
> this category and provide an explanation of each cost in this
> category. In some cases, grantee rent, utilities and insurance fall
> under this category if they are not included in an approved indirect
> cost rate.
>
> **Contractual:** To the extent possible, all contract budgets and
> justifications should be standardized, and contract budgets should be
> presented by using the same object class categories contained in the
> Standard Form 424A. Provide a clear explanation as to the purpose of
> each contract, how the costs were estimated, and the specific contract
> deliverables. Please list both Patient-Care and Non-Patient Care
> contracts.
>
> **Indirect Costs:** Indirect costs are those costs incurred for common
> or joint objectives which cannot be readily identified but are
> necessary to the operations of the organization, e.g., the cost of
> operating and maintaining facilities, depreciation, and administrative
> salaries. For institutions subject to OMB Circular A-122, the term
> "facilities and administration" is used to denote indirect costs. If
> an organization applying for an assistance award does not have an
> indirect cost rate, the applicant may wish to obtain one through HHS's
> Division of Cost Allocation (DCA).  Visit DCA's website at:
> <http://rates.psc.gov/> to learn more about rate agreements, the
> process for applying for them, and the regional offices which
> negotiate them.
>
> If an organization is applying for Federal assistance and it does not
> have a "Federally Negotiated Indirect Costs (IDC) Rate Agreement" all
> costs will be considered direct costs until a rate agreement is
> negotiated with a Federal cognizant agency and provided to HRSA to
> review as part of the budget request. If the application is funded,
> HRSA will reallocate any amount identified under the IDC line item
> budget to the "Other" line item and request a revised budget, which
> clearly identifies how these funds will be expended under the grant
> until the grantee can provide an approved IDC Rate Agreement. **For
> organizations that do have a previously negotiated Federal indirect
> cost rates, these will be accepted but must be included/denoted in the
> budget.**

vi. []{#__RefHeading___Toc151519224 .anchor}***Staffing Plan and
    Personnel Requirements***

> Applicants must present a staffing plan justification (Form 2: 
> Staffing Profile) for the first year of the project which identifies
> the total personnel and number of FTEs to staff the proposed project. 
> Education and experience qualifications should be included in the
> biographical sketches for any key management staff: Chief Executive
> Officer (CEO), Chief Financial Officer (CFO), Chief Medical Officer
> (CMO), Chief Information Officer (CIO), and Chief Operating Officer
> (COO) as applicable in Attachment 6. Position descriptions for key
> management staff that include the roles, responsibilities, and
> qualifications must be also included in Attachment 5. Applicants
> should indicate on the position descriptions if key management
> positions are combined and/or part time (e.g. CFO and COO roles are
> shared). Applicant should also provide a one-page organizational chart
> that depicts the governing board, key personnel, staffing, and any
> subrecipients and/or affiliating organizations in Attachment 5. **Form
> 2: Staffing Profile should be included in Attachment 2: Program
> Specific Forms.**

vii. []{#__RefHeading___Toc151519225 .anchor}***Assurances***

> This form and detailed instructions are available in PHS Application
> Form 5161-1 provided with the application package. Use only the
> "Required" form from Grants.gov. Please do not upload any additional
> forms.

viii.  []{#__RefHeading___Toc151519226 .anchor}***Certifications***

> This form and detailed instructions are available in the PHS
> Application Form 5161-1 provided with the application package. Use
> only the "Required" form from Grants.gov. Please do not upload any
> additional forms.

ix. []{#__RefHeading___Toc151519227 .anchor}***Project Abstract***

> Upload a one page summary of the application under box #15 of the SF
> 424 Face Page. Because the abstract is often distributed to provide
> information to the public and Congress, please prepare this so that it
> is clear, accurate, concise, and without reference to other parts of
> the application. It must include a brief description of the proposed
> grant project including the needs to be addressed, the proposed
> services, and the population group(s) to be served. The project
> abstract must be single-spaced. 
>
> Please place the following at the top of the abstract:

-   Project Title

-   Applicant Name

-   Address

-   Contact Name

-   Contact Phone Numbers (Voice, Fax)

-   E-Mail Address

-   Web Site Address, if applicable

-   Congressional districts within your service area

-   Types of section 330 funding requested in this application (i.e.
    CHC, MHC, HCH, and/or PHPC)

-   Other HRSA funding received

> The project abstract should be a brief synopsis of the
> community/target population(s), the applicant organization, and the
> proposed project.  The project abstract should address: 

-   The need for health services in the community and target
    population(s) including the needs of special populations (migrant
    and seasonal farmworkers, people experiencing homelessness and/or
    residents of public housing);

-   How the proposed project will address the need for health services
    in the community and target populations; and

-   Number of current or proposed patients, encounters, providers,
    service delivery sites and locations, services to be provided,
    including oral health and mental health/substance abuse services.

> **All information provided in the abstract should be consistent with
> data included in the application.**

x.  []{#__RefHeading___Toc151519228 .anchor}***Program Narrative***

> The Program Narrative should be **a detailed picture of the
> community/target population(s) being served, the applicant
> organization, and the organization's plan for addressing the
> identified health care needs/issues of the community/target
> population(s)**. \[See Appendix H: Service Area Competition
> Definitions for a definition of target population and service area.\]
>
> This section of the application should include a description of the
> health care needs of the community/target population(s); factors
> responsible for these needs; community resources available to meet
> identified community health needs; the community planning process and
> community needs assessment that precipitated the grant application;
> how the organization has/will integrate services with other efforts
> toward developing a comprehensive continuum of care for the
> communities served; the extent to which the applicant's project plan
> addresses the specific program requirements (i.e. compliance); and the
> organization's capacity to address the health needs and experience in
> providing services. All applicants are encouraged to review Appendix I
> for additional information on program requirements and expectations.
>
> The Program Narrative should be consistent with the Health Care and
> Business Plans.
>
> All applicants should ensure that the specific elements in the Review
> Criteria are completely addressed. Throughout the Program Narrative,
> reference may be made to exhibits and charts, as needed, in order to
> reflect information about multiple sites and/or geographic or
> demographic data. These exhibits and charts should be included as part
> of the attachments that applicants must upload with the electronic
> submission. **The attachments should not contain any required
> narrative. Response to review criteria for the Health Care and
> Business Plans should be described in the project narrative.**
>
> The following provides a framework for the Program Narrative. It
> should be succinct, self-explanatory and well-organized so that
> reviewers can fully understand the proposed project.
>
> The Program Narrative should be organized using the following section
> headers:

-   ***NEED (15 points)***

> See Criterion 1: NEED in the Review Criteria (p. 34) for the specific
> elements that should be addressed.

-   ***response (25 poINTS)***

> See Criterion 2: RESPONSE in the Review Criteria (p. 38) for the
> specific elements that should be addressed.

-   ***EVALUATIVE MEASURES (5 POINTS)***

> See Criterion 3: EVALUATIVE MEASURES in the Review Criteria (p. 41)
> for the specific elements that should be addressed.

-   ***impact (10 POINTS)***

> See Criterion 4: IMPACT in the Review Criteria (p. 42) for the
> specific elements that should be addressed.

-   ***resources/capabilities (25 POINTS)***

> See Criterion 5: RESOURCES/CAPABILITIES in the Review Criteria (p. 42)
> for the specific elements that should be addressed.

-   ***support Requested* *(10 POINTS)***

> See Criterion 6: SUPPORT REQUESTED in the Review Criteria (p. 44) for
> the specific elements that should be addressed.

-   ***governance** **(10 POINTS)***

> See Criterion 7: GOVERNANCE in the Review Criteria (p. 45) for the
> specific elements that should be addressed.

xi. []{#__RefHeading___Toc151519229 .anchor}***Program Specific Forms***

    Please see Appendix C for Program Specific Forms and Instructions.

xii. []{#__RefHeading___Toc151519231 .anchor}***Attachments***

> Please provide the following items to complete the content of the
> application. Please note that these are supplementary in nature, and
> are not intended to be a continuation of the project narrative. Be
> sure each attachment is clearly labeled.

1)  **Attachment 1: Copy of signed SF-424/5161 Face Sheet. Not counted
    against the page limit.**

2)  **Attachment 2: Program Specific Forms 1 -- 9.**

> Bureau of Primary Health Care (BPHC) program-specific forms #1- 9
> should be uploaded under Attachment #2 under Attachments Form in
> Grants.gov**. These Program Specific Forms DO NOT count against the
> page limit.** All forms should be merged into one document. Please
> note that only the OMB forms, approved by the U.S. Office of
> Management and Budget, should be submitted with the SAC-Additional
> Areas application (included in Appendix C).

-   Forms 1 -- 5, 6 -- Part A, and 9 are required for all applicants.

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```
-   Form 1-Part B - BPHC-Funding Request Summary is **NO LONGER**
    required for SAC-Additional Areas applicants.

-   Form 7 -- Compliance Checklist is **NO LONGER** required for
    SAC-Additional Areas applicants.

-   Only applicants requesting a waiver for governance requirements must
    submit Form 6 -- Part B.[^1]

-   Only CHC and/or MHC applicants must submit Form 8 -- Part A and only
    those CHC and/or MHC applicants with proposed affiliation
    arrangements must submit Form 8 -- Part B.

3)  **Attachment 3: Service Area Map (Required)**

> Applicants must include a map of the service area for the proposed
> project and the organization's point(s) of service (i.e., service
> sites listed in Form 5 - Part B). The map should indicate any
> medically underserved areas (MUAs) and/or medically underserved
> populations (MUPs). The map should also include other Federally
> Qualified Health Centers (FQHC), FQHC Look-Alikes, or other health
> care providers serving the same population(s). For inquiries regarding
> Medically Underserved Areas or Medically Underserved Populations, call
> 1-888-275-4772. Press option 1, then option 2 or contact the Shortage
> Designation Branch via email <sdb@hrsa.gov> or 301-594-0816.

4)  **Attachment 4: Corporate Bylaws, Signed and Dated (Required)**

> Bylaws (in its entirety) should be signed and dated by the appropriate
> individual indicating review and approval by the Governing Board.

5)  **Attachment 5: Project Organizational Chart and Position
    Descriptions for Key Management Staff (Required)**

> Applicants should provide a one-page figure that depicts the governing
> board, key personnel, staffing, and any sub-recipients and/or
> affiliating organizations. Applicants should also provide position
> descriptions for key management staff: Chief Executive Officer (CEO),
> Chief Financial Officer (CFO), Chief Medical Officer (CMO), Chief
> Information Officer (CIO), and Chief Operating Officers (COO) as
> applicable. Applicants should indicate on the position descriptions if
> key management positions are combined and/or part time (e.g. CFO and
> COO roles are shared). Each position description should be limited to
> **one page** or less and must include at a minimum, the position
> title, description of duties and responsibilities, position
> qualifications, supervisory relationships, skills, knowledge and
> experience requirements, travel requirements, salary range, and work
> hours.

6)  **Attachment 6: Biographical Sketches of Key Management Staff
    (Required)**

> Applicants should provide biographical sketches for key management
> staff: Chief Executive Officer (CEO), Chief Financial Officer (CFO),
> Chief Medical Officer (CMO), Chief Information Officer (CIO), and
> Chief Operating Officers (COO) as applicable. Biographical sketches
> should not to exceed **two** pages in length each. In the event that a
> biographical sketch is included for an identified individual who is
> not yet hired, please include a letter of commitment from that person
> with the biographical sketch.

7)  **Attachment 7: Co-Applicant Agreement (Required for Public Center
    Applicants that have a co-applicant board)**

> Public centers[^2] that receive section 330 funding must comply with
> all the applicable governance requirements and regulations. In cases
> where the public centers's board cannot directly meet all applicable
> health center governance requirements, a separate co-applicant health
> center governing board must be established that meets all the section
> 330 governance requirements. Public Center applicants that have such a
> co-applicant board must submit in its entirety, the formal
> co-applicant agreement signed by both the co-applicant governing board
> and the public center. The co-applicant agreement should stipulate
> roles, responsibilities and the delegation of authorities and any
> shared roles and responsibilities of each party in carrying out the
> governance functions.

8)  **Attachment 8: Summary of Contracts, Agreements and Subrecipient
    Arrangements (As Applicable)**

> All applicants with any of the current or proposed agreements listed
> below (a through i) must submit a BRIEF SUMMARY describing these
> agreements. Applicants DO NOT need to discuss contracts for such areas
> as janitorial services. It is suggested that the summary not exceed 3
> pages in total. The summary should address the following items for
> each agreement:

-   Name and contact information for affiliated agency(ies);

-   Type of agreement (i.e. contract, sub-recipient arrangement,
    affiliation agreement, etc.);

-   Brief description of the purpose and scope of the agreement (i.e.
    type of services provided, how/where these are provided.); If the
    agreement is for a subrecipient arrangement, the applicant must
    demonstrate that the relationship between the applicant and
    sub-recipient is in compliance with section 330 requirements; and

-   Timeframe for the agreement/contract/affiliation.

> **Types of current or proposed agreements to be discussed in the
> summary:**
>
> a\) Contract or sub-award for a substantial portion of the proposed
> project
>
> b\) Memorandum of Understanding (MOU)/Agreement (MOA) for a
> substantial portion of the proposed project
>
> c\) Contract with another organization or individual contract for core
> primary care providers
>
> d\) Contract with another organization for staffing health center
>
> e\) Contract with another organization for the Chief Medical Officer
> (CMO) or Chief Financial Officer (CFO)
>
> f\) Merger with another organization
>
> g\) Parent Subsidiary Model arrangement
>
> h\) Acquisition by another organization
>
> i\) Establishment of a New Entity (e.g., Network corporation)

9)  **Attachment 9: Most recent independent financial audit (Required)**

> Audit information will be considered complete when it includes all
> balance sheets, profit and loss statements, audit findings, management
> letters and any noted exceptions. Please provide a detailed
> explanation if audit information is not available for the applicant
> organization.

10) **Attachment 10: Articles of Incorporation (Required)**

> Applicants should submit the official signatory page (seal page) of
> the organization's Articles of Incorporation.

11) **Attachment 11: Letters of Support (Required)**

> Applicants should include any letters of support as appropriate to
> demonstrate support and commitment to the project. Support from local
> community stakeholders, patients, and collaborating organizations are
> as important as letters of support from elected officials. Applicants
> may summarize additional letters in a list.

12) **Attachment 12: Discount Sliding Fee Schedule (Required)**

> Applicants must provide a schedule of discounts that correspond to a
> schedule of charges for which discounts are adjusted on the basis of
> the patient's ability to pay. The schedule of discounts must apply to
> persons with incomes above 100 percent and below 200 percent of the
> Federal poverty level (see the Federal poverty guidelines at
> [[http://aspe.hhs.gov/poverty/]{.underline}](http://aspe.hhs.gov/poverty/))
> and no discount shall be given to patients over 200 percent of
> poverty. In addition, patients at 100% or below poverty must be
> provided services at no charge although a nominal fee may be
> permitted.

13) **Attachment 13: Other Relevant Documents (As applicable)**

> Applicants may include other attachments and documents to support the
> proposed project plan such as charts and organizational brochures.
> Applicant should attach floor plans and lease/intent to lease
> documents for any facilities.

14) **Attachment 14: Health Care Plan and Business Plan (Required)**

> A sample format and guidelines for both the Health Care Plan and
> Business Plan are provided in Appendix E of the guidance.

15) **Attachment 15: Evidence of Non-Profit Status** **(Only applicable
    for organizations that DO NOT already have current evidence of
    non-profit status on file with an agency of HHS)**

> Consistent with the instructions provided in Part D of the HHS
> Checklist Form PHS-5161, a private, nonprofit organization must
> include evidence of its nonprofit status with the application. Any of
> the following is acceptable evidence:

-   A reference to the organization's listing in the Internal Revenue
    Service's (IRS) most recent list of tax-exempt organizations
    described in section 501(c)(3) of the IRS Code.

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-   A copy of a currently valid Internal Revenue Service Tax exemption
    certificate.

-   A statement from a State taxing body, State Attorney General, or
    other appropriate State official certifying that the applicant
    organization has a nonprofit status and that none of the net
    earnings accrue to any private shareholders or individuals.

-   A certified copy of the organization's certificate of incorporation
    or similar document if it clearly establishes the nonprofit status
    of the organization.

-   Any of the above proof for a State or national parent organization,
    and a statement signed by the parent organization that the applicant
    organization is a local nonprofit affiliate.

> If an applicant already has evidence of current nonprofit status on
> file with an agency of HHS, it WILL NOT be necessary to file similar
> papers again, but the place and date of filing must be indicated in
> Part D of the HHS Checklist, Form PHS-5161.
>
> **Applicants are reminded that failure to include all required
> documents as part of the application may result in an application
> being considered as incomplete or non-responsive.**
>
> **The total size of all uploaded files may not exceed the equivalent
> of 150 pages when printed by HRSA**. All non-compliant applications
> that exceed the page limit will be returned to the applicant without
> further consideration.
>
> This page limit does not include the program specific forms
> (identified as Attachment #2) or the financial audit (identified as
> Attachment #9). The page limit also does not include the Application
> for Federal Assistance (SF 424), Grants.gov Lobbying Form, Budget
> Information for Non-Construction Program (SF-424A), HHS Checklist
> (Form 5161-1), Assurances, and Certifications.
>
> **Please note that the page limit [does]{.underline} include the
> project abstract**, **program narrative, budget justification,
> attachments #3 -- #15, and the Health Care and Business Plan Tables.**
>
> **It is highly recommended that applicants print out the application
> before submitting it electronically to ensure that it is within the
> 150-page limit.**

[]{#__RefHeading___Toc151519232 .anchor}**3. Submission Dates and
Times**

**Application Due Date**

> The due dates for applications under this grant announcement are
> **8:00 P.M. ET** as follows, for projects ending in FY 2008:

  -------------------- ----------------- ---------------------------------
  **Project Period     **HRSA            **Grants.gov Application
  Start Date**         Announcement      Deadline**
                       Number**          

  April 1, 2008        HRSA 08-112       February 8, 2008 at 8:00 PM ET

  June 1, 2008         HRSA 08-113       February 8, 2008 at 8:00 PM ET
  -------------------- ----------------- ---------------------------------

> Applications will be considered as meeting the deadline if they are
> electronically marked on or before the due date. Please consult
> Appendix A, Section 3 for detailed instructions on submission
> requirements.
>
> The Chief Grants Management Officer (CGMO) or a higher level designee
> may authorize an extension of published deadlines when justified by
> circumstances such as acts of God (e.g. floods or hurricanes),
> widespread disruptions of mail service, or other disruptions of
> services, such as a prolonged blackout. The authorizing official will
> determine the affected geographical area(s).
>
> Applications must be submitted by 8:00 P.M. ET by the due date listed.
> **To ensure that you have adequate time to follow procedures and
> successfully submit the application, we recommend that you register
> immediately in Grants.gov and complete the forms as soon as possible,
> as this is a new process and may take some time.**
>
> **The registration process can take up to one month.** **Please refer
> to Appendix B for information on registering, and Appendix A, Section
> 3 for information on applying through Grants.gov.** **If you do not
> complete the registration process, you will be unable to submit an
> application. Applicants are strongly encouraged to register multiple
> authorizing organization representatives.**
>
> Per section 330(k)(3)(H) of the PHS Act (42 U.S.C. 254b), the health
> center governing board must approve the health center's annual budget
> and approve applications for subsequent grants for the health center. 
> In addition, the SF-424 face page, included in the required PHS 5161
> Grant Application and which must be signed by the applicant's
> authorized representative (most often the Executive Director, Program
> Director, or Board Chair). certifies that all data in the application
> are true and correct and that the document has been duly authorized by
> the governing body of the applicant.  It also certifies that the
> applicant will comply with the attached assurances if the assistance
> is awarded. Selection of the responsible person should be consistent
> with responsibilities authorized by the organization's bylaws.
>
> **Authorized representatives that sign the SF-424 are reminded that a
> copy of the governing board's authorization for them to sign this
> application as official representative must be on file in the
> applicant's office and that their signature also assures that the
> governing board has reviewed and approved ALL content of the
> application, including the program specific forms.**
>
> **Late applications:**
>
> Applications which do not meet the criteria above are considered late
> applications. Health Resources and Services Administration (HRSA)
> shall notify each late applicant that its application will not be
> considered in the current competition.

[]{#__RefHeading___Toc151519235 .anchor}**4. Intergovernmental Review**

> **The Health Center Program is subject to the provisions of Executive
> Order 12372, as implemented by 45 CFR Part 100**. Executive Order
> 12372 allows States the option of setting up a system for reviewing
> applications from within their States for assistance under certain
> Federal programs. Application packages made available under this
> guidance will contain a listing of States that have chosen to set up
> such a review system, and will provide a State Single Point of Contact
> (SPOC) for the review. Information on states affected by this program
> and State Points of Contact may also be obtained from the Grants
> Management Officer listed in the AGENCY Contact(s) section, as well as
> from the following Web site:
> <http://www.whitehouse.gov/omb/grants/spoc.html>.
>
> All applicants other than federally recognized Native American Tribal
> Groups should contact their SPOC as early as possible to alert them to
> the prospective applications and receive any necessary instructions on
> the State process used under this Executive Order.
>
> For proposed projects serving more than one State, the applicant is
> advised to contact the SPOC of each affected State. The due date for
> State process recommendations is 60 days after the applicable Federal
> application receipt due date. (See "Intergovernmental Review of
> Federal Programs," Executive Order 12372, and 45 CFR Part 100, for
> description of the review process and requirements.)
>
> **Public Health System Reporting Requirements**: Under these
> requirements (approved by the Office of Management and Budget,
> 0937-0195), the community-based non-governmental applicant must
> prepare and submit a Public Health System Impact Statement (PHSIS) to
> the head of the appropriate State and local health agencies in the
> area(s) to be impacted no later than the Federal application due date.
> The PHSIS should include:
>
> a\) A copy of the face page of the application (SF 424).
>
> b\) A summary of the project, not to exceed one page, which provides:

-   A description of the population to be served, whose needs would be
    met under the proposal.

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-   A summary of the services to be provided, and

-   A description of the coordination planned with the appropriate State
    or local health agencies.

> Applicants should contact their state Primary Care Association for
> instructions on how and where to submit the Public Health Impact
> statement.

[]{#Application_fundingrestrictions .anchor}

**5. Funding Restrictions**

> Applicants responding to this announcement may request funding for a
> project period of up to five (5) years. Funding requests should be
> consistent with the current level of Federal section 330 funding in
> the announced service area. Awards to support projects beyond the
> first budget year will be contingent upon Congressional appropriation,
> satisfactory progress in meeting the project's objectives, and a
> determination that continued funding would be in the best interest of
> the government.
>
> Federal funding levels and the length of project period may be
> adjusted based on an analysis of performance and actual experience,
> and/or the budget operating costs, utilization, provider staffing and
> revenue generation for the specific service area. See Section IV.
> Budget of this application guidance for further information and
> instruction on the development of the application budget.
>
> Applicants currently receiving section 330 funding and applying to
> serve their current service area should ensure that their application
> reflects their current approved scope of project. Any proposed changes
> in scope requiring prior approval MUST be submitted under separate
> cover. The change in scope application must be emailed to
> <bphcscope@hrsa.gov> and a signed original must be sent to the HRSA's
> Division of Grants Management Operations with a courtesy copy to the
> Project Officer. Please refer to the most recent guidance on this
> subject contained in PIN 2002-07: Scope of Project Policy (available
> onsite at [www.bphc.hrsa.gov](http://www.bphc.hrsa.gov/)), or contact
> <BPHCscope@hrsa.gov> for more information.
>
> Funds under this announcement may not be used for construction of
> facilities.

[]{#__RefHeading___Toc151519237 .anchor}**6. Other Submission
Requirements**

> As stated in Section IV.I, except in rare cases, HRSA will no longer
> accept applications for grant opportunities in paper form. Applicants
> for this funding opportunity are ***required*** to submit
> ***electronically*** through Grants.gov. To submit an application
> electronically, please use the
> [http://www.grants.gov](http://www.grants.gov/) apply site. When using
> Grants.gov you will be able to download a copy of the application
> package, complete it off-line, and then upload and submit the
> application via the Grants.gov site.
>
> As soon as you read this, whether you plan on applying for a HRSA
> grant later this month or later this year, it is incumbent that your
> organization **immediately register** in Grants.gov and become
> familiar with the Grants.gov site application process. If you do not
> complete the registration process you will be unable to submit an
> application. The registration process can take up to one month, so you
> need to begin immediately.
>
> To be able to successfully register in Grants.gov, it is necessary
> that you complete all of the following required actions:
>
> • Obtain an organizational Data Universal Number System (DUNS) number
>
> • Register the organization with Central Contractor Registry (CCR)
>
> • Identify the organization's E-Business POC (Point of Contact)
>
> • Confirm the organization's CCR "Marketing Partner ID Number (M-PIN)"
> password
>
> • Register an Authorized Organization Representative (AOR)
>
> • Obtain a username and password from the Grants.gov Credential
> Provider
>
> Instructions on how to register, tutorials and FAQs are available on
> the Grants.gov web site at [www.grants.gov](http://www.grants.gov/).
> Assistance is also available from the Grants.gov help desk at
> <support@grants.gov> or by phone at 1-800-518-4726.
>
> More specific information, including step-by-step instructions on
> registering and applying can be found in Appendix B of this guidance.
>
> **Formal submission of the electronic application:** Applications
> completed online are considered formally submitted when the
> Authorizing Official electronically submits the application to HRSA
> through Grants.gov You must, however, ensure that a copy of the
> SF-424/5161 Face Sheet is printed, [signed]{.underline},
> [scanned]{.underline}, and included with your electronic application
> submission as **Attachment 1**. The SF-424/5161 **must be** printed
> from Grants.gov.
>
> Per section 330(k)(3)(H) of the PHS Act (42 U.S.C. 254b), the health
> center governing board must approve the health center's annual budget
> and approve applications for subsequent grants for the health center. 
> In addition, the SF-424 face page, included in the required PHS 5161
> Grant Application and which must be signed by the applicant's
> authorized representative (most often the Executive Director, Program
> Director, or Board Chair), certifies that all data in the application
> are true and correct and that the document has been duly authorized by
> the governing body of the applicant.  It also certifies that the
> applicant will comply with the attached assurances if the assistance
> is awarded. Selection of the responsible person should be consistent
> with responsibilities authorized by the organization's bylaws.
>
> **Authorized representatives that sign the SF-424 are reminded that a
> copy of the governing board's authorization for them to sign this
> application as official representative must be on file in the
> applicant's office and that their signature also assures that the
> governing board has reviewed and approved ALL content of the
> application, including the program specific forms.**
>
> Applications will be considered as having met the deadline if: (1) the
> application has been successfully transmitted electronically by your
> organization's Authorizing Official through Grants.gov on or before
> the deadline date and time, and (2) the signed SF-424/5161 Face Sheet
> is included in the electronic application submission.
>
> **It is incumbent on applicants to ensure that the AO is available to
> submit the application to HRSA by the application due date. We will
> [not]{.underline} accept submission or re-submission of incomplete,
> rejected, or otherwise delayed applications after the deadline.**
>
> **Again, please understand that we will not consider additional
> information and/or materials submitted after your initial application.
> You must therefore ensure that all materials are submitted together.
> Further information on the HRSA electronic submission policy can be
> obtained at <http://www.hrsa.gov/grants/electronicsubmission.htm>.**

[]{#__RefHeading___Toc151519238 .anchor}**V. Application Review
Information**

[]{#__RefHeading___Toc151519239 .anchor}**1. Review Criteria**

> Procedures for assessing the technical merit of grant applications
> have been instituted to provide for an objective review of
> applications and to assist the applicant in understanding the
> standards against which each application will be judged. Critical
> indicators have been developed for each review criterion to assist the
> applicant in presenting pertinent information related to that
> criterion and to provide the reviewer with a standard for evaluation.
> Review criteria are outlined below with specific detail and scoring
> points.
>
> Review Criteria are used to review and rank applications. The
> SAC-Additional Areas has 7 review criteria. All applicants should
> ensure the review criteria are fully addressed within the Program
> Narrative and supported by other supplementary information in the
> other sections of the application as appropriate.
>
> HRSA is committed to ensuring access to quality health care for all.
> Quality care means access to services, information, and materials
> delivered by competent providers in a manner that factor in the
> language needs, cultural richness, and diversity of populations
> served. Quality also means that, where appropriate, data collection
> instruments used should adhere to culturally competent and
> linguistically appropriate norms. For additional information and
> guidance, refer to the National Standards for Culturally and
> Linguistically Appropriate Services in Health Care published by the
> U.S. Department of Health and Human Services. This document is
> available online at <http://www.orhrc.gov/CLAS>.
>
> Wherever appropriate within the review criteria, identify programs,
> training and technical assistance implemented to improve health
> communications to foster healing relationships across culturally
> diverse populations.
>
> Wherever appropriate within the review criteria, describe the
> program's or institution's strategic plan, policies, and initiatives
> that demonstrate a commitment to providing culturally and
> linguistically competent health care and developing culturally and
> linguistically competent health care providers, faculty, staff, and
> program participants. This includes participation in, and, support of
> programs that focus on cross-cultural health communication approaches
> as strategies to educate health care providers serving diverse
> patients, families, and
>
> communities.
>
> **Criterion 1: NEED (15 Points)**

1\. Based on the applicant's most recent needs assessment and other
available data, please respond to the most relevant factors impacting
access to care and unmet need for primary care in the target population
to be served within the proposed service area. **Information provided on
need should serve as the basis for, and align with, the proposed
activities and objectives described in the health care and business
plans and throughout the application.**

> **Data provided should not be based solely on the current or proposed
> patients of the organization but rather, on the total stated target
> population (including special or proposed populations if applicable:
> migrant and seasonal farmworkers, people experiencing homelessness
> and/or residents of public housing) to be served within the proposed
> service area.** Responses to all indicators must be expressed in the
> same unit of analysis identified in the specific barrier or disparity
> (e.g. a mortality ratio can not be used to provide a response to
> "age-adjusted death rate").
>
> *Please note that the Health Resources and Services Administration has
> developed a Data Resource Guide to assist communities in identifying
> their unique health disparities and other factors impacting access to
> care for their communities, available at
> [www.bphc.hrsa.gov](http://www.bphc.hrsa.gov/). While data sources are
> provided in the Data Resource Guide for all barrier and disparity
> indicators, applicants may use alternate data sources to provide their
> responses.*

a)  Applicant should provide responses for the following three (3)
    barriers. **All responses must be expressed in the unit and format
    requested.** Briefly describe in 2 to 3 sentences the context and
    relationship of these barriers to access primary care for the target
    population within the proposed service area.

    1.  Population to Primary Care Physician FTE Ratio

    2.  Percent of Population at or below 200 Percent of Poverty

    3.  Percent of Population Uninsured

b)  Applicant should provide responses to two (2) of the following
    five (5) barriers. **All responses must be expressed in the unit and
    format requested.** Briefly describe in 2 to 3 sentences the context
    and relationship of the selected barriers to access primary care for
    the target population within the proposed service area.

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1.  Distance (miles) or travel time (minutes) to nearest primary care
    provider accepting new Medicaid patients and/or uninsured patients

2.  Percent of population linguistically isolated (percent of people 5
    years and over who speak a language other than English at home)

3.  Age-Adjusted Death Rate

4.  12-month average unemployment rate

5.  Waiting time for public housing where public housing exists

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c)  Applicant should provide a response to one (1) disparity measure
    indicator [**from within each of the disparity categories
    below**:]{.underline} Diabetes/Obesity, Cardiovascular Disease,
    Asthma/Respiratory Disease, Prenatal and Perinatal Health, and
    Mental Health/Substance Abuse/Behavioral Health. **All responses
    must be expressed in the unit and format requested.** For each
    response, applicant must provide the current value for the target
    population within the proposed service area. The applicant may elect
    to provide an alternate indicator to each of the disparity
    categories under \"Other,\" rather than respond to one of the
    identified indicators within the disparity category. If providing an
    "Other" disparity category indicator, the applicant must specify the
    disparity category indicator definition to be used, data source
    used, and rationale for using this alternative disparity category
    indicator. Briefly describe in 1 to 2 paragraphs the context and
    relationship of selected indicators to the health status of the
    target population within the proposed service area.

> **[DISPARITY CATEGORIES & INDICATORS]{.underline}**

+-----------------------------------------------------------------------+
| **Diabetes, Obesity (Pick 1)**                                        |
+-----------------------------------------------------------------------+
| > \(a\) Diabetes Short-term Complication Hospital Admission Rate      |
+-----------------------------------------------------------------------+
| > \(b\) Diabetes Long-term Complication Hospital Admission Rate       |
+-----------------------------------------------------------------------+
| > \(c\) Uncontrolled Diabetes Hospital Admission Rate                 |
+-----------------------------------------------------------------------+
| > \(d\) Rate of Lower-extremity Amputation Among Patients with        |
| > Diabetes                                                            |
+-----------------------------------------------------------------------+
| > \(e\) Age Adjusted Diabetes Prevalence                              |
+-----------------------------------------------------------------------+
| > \(f\) Adult Obesity Prevalence                                      |
+-----------------------------------------------------------------------+
| > \(g\) Diabetes Mortality Rate -- (Number of deaths per 100,000      |
| > reported as due to diabetes as the underlying cause or as one of    |
| > multiple causes of death (ICD-9 Code 250))                          |
+-----------------------------------------------------------------------+
| > \(h\) Other                                                         |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Cardiovascular Disease (Pick 1)**                                   |
+-----------------------------------------------------------------------+
| > \(a\) Hypertension Hospital Admission Rate                          |
+-----------------------------------------------------------------------+
| > \(b\) Congestive Heart Failure Hospital Admission Rate              |
+-----------------------------------------------------------------------+
| > \(c\) Angina without Procedure Hospital Admission Rate              |
+-----------------------------------------------------------------------+
| > \(d\) Mortality from Diseases of the Heart - (Number of deaths per  |
| > 100,000 reported as due to heart disease (includes ICD-9 Codes      |
| > 100-109, 111, 113, and 120-151))                                    |
+-----------------------------------------------------------------------+
| > \(e\) Proportion of Adults reporting diagnosis of high blood        |
| > pressure                                                            |
+-----------------------------------------------------------------------+
| > \(f\) Other                                                         |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Asthma, Respiratory Disease (Pick 1)**                              |
+-----------------------------------------------------------------------+
| > \(a\) Adult Asthma Hospital Admission Rate                          |
+-----------------------------------------------------------------------+
| > \(b\) Pediatric Asthma Hospital Admission Rate                      |
+-----------------------------------------------------------------------+
| > \(c\) Chronic Obstructive Pulmonary Disease Hospital Admission Rate |
+-----------------------------------------------------------------------+
| > \(d\) Bacterial Pneumonia Hospital Admission Rate                   |
+-----------------------------------------------------------------------+
| > \(e\) Three Year Average Pneumonia Death Rate - (Three year average |
| > number of deaths per 100,000 due to pneumonia (includes ICD -- 9    |
| > Codes 480-486))                                                     |
+-----------------------------------------------------------------------+
| > \(f\) Adult Current Asthma Prevalence                               |
+-----------------------------------------------------------------------+
| > \(g\) Adult Ever Told Had Asthma                                    |
+-----------------------------------------------------------------------+
| > \(h\) Other                                                         |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Prenatal and Perinatal Health (Pick 1)**                            |
+-----------------------------------------------------------------------+
| > \(a\) Low Birth Weight Rate, 5 year average                         |
+-----------------------------------------------------------------------+
| > \(b\) Infant Mortality Rate, 5 year average                         |
+-----------------------------------------------------------------------+
| > \(c\) Births to Teenage Mothers (15-19)                             |
+-----------------------------------------------------------------------+
| > \(d\) Late entry into prenatal care (entry after first trimester)   |
+-----------------------------------------------------------------------+
| > \(e\) Cigarette use during pregnancy                                |
+-----------------------------------------------------------------------+
| > \(e\) Other                                                         |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Mental Health/Substance Abuse/Behavioral Health (Pick 1)**          |
+-----------------------------------------------------------------------+
| > \(a\) Depression Prevalence                                         |
+-----------------------------------------------------------------------+
| > \(b\) Suicide Rate                                                  |
+-----------------------------------------------------------------------+
| > \(c\) Youth Suicide attempts requiring medical attention            |
+-----------------------------------------------------------------------+
| > \(d\) Adults with Mental disorders not receiving treatment          |
+-----------------------------------------------------------------------+
| > \(e\) Any Illicit Drug Use in the Past Month (Adults)               |
+-----------------------------------------------------------------------+
| > \(f\) Heavy alcohol use 12 and over                                 |
+-----------------------------------------------------------------------+
| > \(g\) Homeless with severe mental illness                           |
+-----------------------------------------------------------------------+
| > \(h\) Other                                                         |
+-----------------------------------------------------------------------+

> d.) Applicant should provide responses to five (5) out of the ten (10)
> disparities listed below. **All responses must be expressed in the
> unit and format requested.** Applicants can propose to fulfill up to
> two (2) of the required 5 disparity factors using an "Other"
> indicator. If providing an "Other" disparity indicator, the applicant
> must specify the disparity category indicator definition to be used,
> data source used, and rationale for using this alternative disparity
> category indicator. Briefly describe in 1 to 2 paragraphs the context
> and relationship of selected factors to the health status of the
> target population within the proposed service area.

+-----------------------------------------------------------------------+
| **DISPARITY FACTORS (Pick 5)**                                        |
+-----------------------------------------------------------------------+
| Oral Health - % without dental visit in last year                     |
+-----------------------------------------------------------------------+
| HIV Infection Prevalence                                              |
+-----------------------------------------------------------------------+
| Percent of children not receiving recommended immunizations 4-3-1-3-3 |
|                                                                       |
| (4 DTaP, 3 polio, 1 MMR, 3 Hib, 3 hepatitis B)                        |
+-----------------------------------------------------------------------+
| Percent Elderly (65 and older)                                        |
+-----------------------------------------------------------------------+
| Cancer Screening -- No Pap test in past 3 years; women 18+            |
+-----------------------------------------------------------------------+
| Cancer Screening -- No Mammogram in past 3 years; women 40+           |
+-----------------------------------------------------------------------+
| Cancer Screening -- No Fecal Occult Blood Test within the past 2      |
| years; adults 50+                                                     |
+-----------------------------------------------------------------------+
| Unintentional Injury Deaths                                           |
+-----------------------------------------------------------------------+
| Other                                                                 |
+-----------------------------------------------------------------------+
| Other                                                                 |
+-----------------------------------------------------------------------+

2\. Please provide a description of the unique characteristics of the
target population within the proposed service area that affect access to
care, health care utilization and/or health status. **This section**
**should not restate items previously cited in question #1,** but rather
describe additional aspects of need that are not captured by
quantitative data. **Information provided on need should serve as the
basis for, and align with, the proposed activities and objectives
described in the health care and business plans and throughout the
application.** Applicant should reference Attachment 3: Service Area Map
if applicable. The description should include:

a.  Cultural/ethnic factors including attitudes, knowledge, and/or
    beliefs;

b.  Geographical/transportation barriers;

c.  Limited English proficiency or educational factors; and

d.  Unique health care needs of the target population(s) not previously
    addressed. An applicant who does not receive targeted funding[^3] to
    serve migrant and seasonal farmworkers, people experiencing
    homelessness and/or residents of public housing, but currently serve
    or may serve these populations in the future are encouraged to
    discuss the unique health care needs of these populations as well.

3\. Applicant demonstrates a thorough understanding of the health care
environment and describes any significant changes over the past five
years that have affected the applicant's ability to provide services
and/or have affected the applicant's fiscal stability, if applicable.
**Information provided on need should serve as the basis for, and align
with, the proposed activities and objectives described in the health
care and business plans and throughout the application.** The topics may
include:

a)  The implementation of Medicaid 1115 or 1915(b) waivers; changes in
    SCHIP coverage; shifts or changes in State Medicaid prospective
    payment systems, Medicaid managed care, Medicare, current or
    proposed changes in State or Federal legislation (e.g. welfare or
    immigration reform initiatives, etc).

b)  Major events including changes in the economic or demographic
    environment of the service area (e.g. influx of refugee population,
    closing of local hospitals, community health care providers or major
    local employers, major emergencies such as hurricanes, flooding,
    terrorism, etc.).

c)  If applicable, discuss the impact of any significant changes
    affecting the special populations served (e.g. migrant/seasonal
    farmworkers, homeless, and residents of public housing).

    4\. Please describe the major gaps or duplications in primary and
    preventive care services (including mental health/substance abuse
    and oral health) currently available in the applicant's service area
    (e.g. willingness of other providers to accept Medicaid or uninsured
    patients, provider shortages, role of any other providers who
    currently serve the target population). **Information provided on
    need should serve as the basis for, and align with, the proposed
    activities and objectives described in the health care and business
    plans and throughout the application.**

**Criterion 2: RESPONSE (25 Points)**

1\. Applicant briefly describes how the community's needs (as described
in Criterion 1 -- Need) and evaluative measures and findings (e.g.
patient satisfaction) are incorporated in its ongoing strategic planning
process.

2\. Applicant demonstrates that its service delivery model(s) is
appropriate and responsive to the identified community health care
needs. All sites and activities described should be consistent with
those listed in Form 5-B and 5-C. Specifically, applicant discusses:

> \(a\) Locations where services are provided and how services will be
> provided (e.g. on-site, mobile vans, by referrals, via contract) at
> each proposed site (Applicants should reference Attachment 3: Service
> Area Map if applicable).
>
> \(b\) How the organization's hours of operation assure that services
> are available and accessible at times that meets the needs of the
> population, including arrangements that assure access to care when the
> organization is closed.

3\. Applicant describes how the following health services are
appropriate for the needs of the target population and are available and
accessible to all life cycles without regard to ability to pay.
(Services discussed should be consistent with those listed in Form 5-A
and the form should be referenced as applicable.) **Any changes to the
delivery manner of these services (direct vs. by referral) must be
addressed as well.**[^4] Applicant should specifically describe:

a)  The provision of required primary health care services,[^5]
    including whether these are provided directly or by referral.

b)  Any arrangements, including whether these are provided directly or
    by referral, for mental health/substance abuse services.

c)  Any arrangements for oral health care services, including whether
    these are provided directly or by referral.

d)  How services will be culturally and linguistically appropriate (e.g.
    availability of interpreter/translator services,
    bilingual/multicultural staff, training opportunities, etc.).

e)  How enabling services, including outreach and transportation, have
    been integrated into the primary care delivery system.

4\. Applicant demonstrates how its established schedule of charges is
consistent with locally prevailing rates or charges and designed to
cover the reasonable costs of operation for services and how its
corresponding schedule of discounts (often referred to as a sliding fee
scale) ensures that no patient will be denied services due their
inability to pay. **Please reference the discount sliding fee schedule
in Attachment 12 in your response.** Applicants should specifically
address:

a)  How often the governing board reviews and updates the organization's
    fee and discount schedule.

b)  How the organization ensures that signs announcing the availability
    of discounts are in a visible and accessible location and how
    patients are made aware of the discount option through other
    publicly distributed materials such as registration materials.

> ***Note:*** Ability to pay is determined by a patient's annual income
> and family size according to the most recent Federal Poverty
> Guidelines for the contiguous 48 states, Alaska and Hawaii
> (Information available at:
> [[http://aspe.hhs.gov/poverty/]{.underline}](http://aspe.hhs.gov/poverty/)).
> Applicants must assure that no patient will be denied health care
> services due to a person's inability to pay. Regulations require that
> the schedule of discounts must:

-   Be available for all individuals and families with an annual income
    below 200 percent of the poverty guidelines.

-   Provide for a full (100 percent) discount for all individuals and
    families with an annual income below 100 percent of the poverty
    guidelines. However, nominal fees may be collected from individual
    or families with an annual income at or below 100 percent of the
    poverty guidelines when imposition of such a fee is consistent with
    project goals and does not pose a barrier to receiving care.

-   A sample schedule of discounts is available in PIN 2003-21 at:
    <ftp://ftp.hrsa.gov/bphc/docs/2003pins/2003-21.pdf> (p. 27 \--
    "EXAMPLE OF A SCHEDULE OF DISCOUNTS").

5\. Applicant describes the incorporation of disease/care management
activities into its quality assurance program and the impact of this on
the organization and/or delivery of services. Applicants should also
describe how the disease/care management activities relate to their
stated needs and how the organization has/or will implement these
activities **at all delivery sites and for all populations**. This
should be consistent with the information included in the Health Care
Plan.

6\. Applicant describes both formal and informal collaboration and
coordination of services with other health care providers, specifically
existing section 330 grantees, Federally Qualified Health Center
Look-Alikes, HRSA and other federally-supported grantees including Ryan
White programs, State and local health services delivery projects,
private providers and programs serving the same population(s) (e.g.
social services, job training, Women, Infants and Children (WIC),
coalitions, community groups, etc.). This should include a description
of:

a)  How a seamless continuum of care is assured.

b)  Referral relationships for additional health services and specialty
    care and with other health care providers including one or more
    hospitals.

c)  Relevant agreements with outside organizations, including contracts,
    Memorandum of Understanding (MOU)/Agreement (MOA) that support the
    project's operation and provision of primary care services (e.g.
    outreach, health education, transportation, etc).

> **Note:** While applicants should describe the contracts, MOAs or MOUs
> above, actual copies of these agreements should NOT be attached unless
> they constitute a substantial portion of the proposed project.

*Health Care Plan (Maximum 10 of 25 total points for Response section)*

7.  Applicant clearly outlines within their Health Care Plan, measurable
    goals and objectives toward improving patient health outcomes,
    eliminating health disparities, and increasing access to primary and
    preventive health care services for the target populations and all
    life cycles (see Guidelines for developing the Health Care Plan in
    the Appendix E). The applicant MAY BUT IS NOT REQUIRED TO provide a
    brief narrative describing any additional information relevant to
    the health care plan such as challenges faced in meeting stated
    objectives and timelines. Optional narrative should be included with
    this question.

> **Note:** Applicants currently receiving section 330 funding and are
> applying to serve their current service area should include relevant
> measures developed as a result of their HRSA Office of Performance
> Review (OPR) site visit in the Health Care Plan if they have received
> a site visit. The applicant is also encouraged to consider Healthy
> People 2010 goals and objectives when developing its Health Care Plan.
> In addition, the applicant should cite evidence-based guidelines in
> the development of their measures to improve performance, quality and
> outcomes. Evidence-based guidelines may include, but are not limited,
> to Health Disparities Collaboratives measures, Health Plan Employer
> Data and Information Set (HEDIS) measures, accreditation standards and
> Relative Value Units.
>
> Information provided on need should serve as the basis for, and align
> with, the proposed activities and objectives described in the health
> care and business plans and throughout the application.
>
> An applicant who is applying to serve migrant populations, people
> experiencing homelessness and/or residents of public housing must
> include appropriate goals and objectives relevant to the needs of
> these populations. Applicants that currently serve or plan to serve
> but do not receive targeted funding for these populations are also
> encouraged to include relevant goals and objectives reflecting these
> needs.
>
> *[It is suggested that the Health Care Plan Table should not exceed 15
> pages]{.underline}.*

**Criterion 3: EVALUATIVE MEASURES (5 points)**

1.  Applicant describes the project's performance monitoring process and
    evaluation systems for health services. Information provided should
    be consistent with the Health Care and Business Plans. Please
    discuss the following areas related to evaluation and monitoring
    capacity:

    a.  Management information systems;

    b.  Quality assurance activities;

    c.  Data collection methods and tools, including those used for
        health outcome measures addressed in the applicant's health care
        plan; and

    d.  Methods for measuring and evaluating patient satisfaction.

2.  Applicant describes the project's risk management procedures,
    including improving patient safety, resolving patient grievances,
    credentialing and privileging, incident management, and
    confidentiality of patient records.

**Criterion 4: IMPACT (10 points)**

1.  Applicant discusses why it is the appropriate entity to receive
    funding by demonstrating its experience and expertise in:

    a.  Working with the target population(s);

    b.  Addressing the target population's identified health care needs;

    c.  Developing and implementing appropriate systems and services;
        and

    d.  Collaborating with and securing support from the local
        community.

> Applicant should provide letters of support, commitment and/or
> investment (e.g. from the school board, local hospital, public health
> department, relevant state health care associations, homeless
> shelters, advocacy groups, and other service providers, etc.). These
> items should be included in Attachment 11: Letters of Support and
> referenced as appropriate.

**Criterion 5: RESOURCES/CAPABILITIES (25 points)**

1.  All applicants should demonstrate that the organizational structure,
    including any subrecipient(s) (see definition of subrecipient(s) in
    Appendix H: Service Area Competition Definitions) or affiliation
    arrangement (as referenced in Form 8-A), is in accordance with
    Health Center Program Expectations[^6] and is appropriate for the
    operational and oversight needs of the project. **Applicant should
    summarize ALL current or proposed subrecipient** arrangements,
    contracts and/or other agreements (as applicable) in Attachment 8.

2.  Applicant describes how lines of authority from the governing board
    to the Chief Executive Officer/Executive Director down to the
    management structure are maintained and are in accordance with
    Health Center Program Expectations. (Please reference Attachment 4:
    Corporate Bylaws, Attachment 5: Project Organizational Chart, and,
    as applicable: Attachment 7: Co-Applicant Agreement (for Public
    Entities that have a co-applicant board),[^7] Attachment 8: Summary
    of Contracts, Agreements and Subrecipient Arrangements.

3.  Applicant describes how the key management staff: Chief Executive
    Officer (CEO), Chief Financial Officer (CFO), Chief Medical Officer
    (CMO), Chief Information Officer (CIO), and Chief Operating Officers
    (COO) as applicable, is appropriate and adequate for the size,
    operational and oversight needs and scope of the proposed project
    and is in accordance with Health Center Program Expectations.[^8] If
    management positions are combined and/or part time (e.g. CFO and COO
    roles are shared), this should be discussed as well.

> Applicant should discuss any key management staff changes in the last
> year, as applicable, and describe its plan for recruiting and
> retaining key management staff including any key management long term
> vacancies.
>
> Applicant should provide position descriptions that include the roles,
> responsibilities, and qualifications as well as bio-sketches for the
> CEO, CFO, CMO, CIO, and COO as applicable. These should be included in
> Attachment 5: Project Organizational Chart and Position Descriptions
> for Key Management Staff and Attachment 6: Biographical Sketches of
> Key Management Staff.

4.  Applicant describes how the proposed clinical staffing plan (e.g.
    number and mix of primary care physicians and other providers and
    clinical support staff, language and cultural competence) is
    appropriate for the level and mix of services to be provided.
    Applicant must also describe its plan for recruiting and retaining
    health care providers as appropriate for achieving the proposed
    staffing plan. The applicant should reference Form 2 and Form 5-Part
    A in their response as appropriate. If the clinical staffing plan
    includes a substantial portion of contracted providers, the
    applicant should include a summary of all such current or proposed
    contracts in Attachment 8.

5.  An applicant who is not receiving section 330 funding to serve an
    area listed in Appendix F **MUST** demonstrate that the timeline for
    service delivery is reasonable to assure that within 120 days of
    grant award the applicant will:

    a.  Be operational;

    b.  Have appropriate staff and providers in place;

    c.  Deliver services at the same or comparable level as presently
        being provided to the entire announced service area;

    d.  An applicant representing a consortium of health centers must
        describe how the partnership structure is accountable to all
        consortium members and will ensure that the decision-making
        process surrounding use of grant funds and program
        implementation will be representative of the entire consortium.

> ***An applicant that currently receives section 330 funding and who is
> applying to serve their current service area should indicate
> "Not-Applicable" for this question.***

3.  Applicant must describe the project's facility(ies) and demonstrate
    that they are appropriate for the service delivery plan. If
    facilities are not currently owned or under a lease agreement, the
    applicant should provide a summary of relevant contracts, MOUs (e.g.
    with homeless shelter, public housing authority, other partner
    organizations) describing how access to facilities and on-site space
    is assured, in Attachment 8.

> The applicant should attach floor plans and lease/intent to lease
> documents for any facilities in Attachment 13: Other Relevant
> Documents.

4.  Applicant demonstrates financial viability and appropriate
    management and control policies and procedures which are in
    accordance with sound financial management procedures, including the
    provision for an audit on an annual basis. The most recent financial
    audit and management letter should be referenced and included in
    Attachment 9, when applicable.

5.  Applicant discusses the status of emergency preparedness planning
    and development of emergency management plans, including
    participation or attempts to participate with State and local
    emergency planners. Applicant should address any "No" response
    provided in Form 9. Specific goals and objectives related to
    emergency preparedness and management should also be addressed in
    the business plan.

Business Plan *(Maximum 10 points of 25 total points in
Resources/Capabilities section):*

6.  Applicant clearly outlines a Business Plan with time-framed,
    measurable and targeted goals/objectives for the operation of the
    organization and ties them into the strategic planning of the
    organization (see instructions and sample chart in Appendix E). The
    applicant MAY BUT IS NOT REQUIRED TO provide a brief narrative
    describing any additional information relevant to the business plan
    such as challenges faced in meeting stated objectives and timelines.
    Optional narrative should be included with this question.

> **Note:** Information provided in the needs assessment should serve as
> the basis for, and align with, the proposed activities and objectives
> described in the business plan and throughout the application.
>
> Applicants currently receiving section 330 funding and who are
> applying to serve their current service area should include relevant
> measures developed as a result of their HRSA Office of Performance
> Review (OPR) site visit in the Business Plan if they have received a
> site visit. *[It is suggested that the Business Plan Table should not
> exceed 15 pages]{.underline}.*

**Criterion 6: SUPPORT REQUESTED (10 points)**

1.  Applicant provides a complete and clear budget presentation
    (SF-424A, budget justification, Form 2: Staffing Profile, and Form
    3: Income Analysis) and describes:

> \(a\) How the total budget is aligned and consistent with the
> applicant's proposed service delivery plan.
>
> \(b\) How reimbursement is or will be maximized from third
> party-payors (e.g. Medicare, Medicaid, SCHIP, private insurance, etc.)
> given the patient mix and number of projected patients and encounters.
>
> \(c\) How the proportion of requested Federal grant funds is
> appropriate given other sources of income discussed in (b) and
> specified in Form 3: Income Analysis.

2\. Applicant demonstrates capacity for achieving cost-effectiveness in
its operations. Specifically the applicant:

(a) Discusses the establishment of appropriate eligibility
    determination, billing and collection practices, including those
    relevant for applicants participating in managed care or prepaid
    plans.

(b) Discusses any activities or procedures designed to evaluate the
    necessity, appropriateness, and efficiency of the use of services,
    procedures, and facilities.

(c) Describes what financial information systems are in place (or
    planned) that are capable of tracking/analyzing/reporting key
    aspects of the organization\'s financial status (e.g. revenue
    generation by source, aged accounts receivable by income source,
    provider productivity, encounters by payor category).

**Criterion 7: GOVERNANCE (10 points)**

1.  Applicant's signed by-laws (see Attachment 4) or other relevant
    attachments demonstrate compliance with the requirements of section
    330(k)(3)(H) of the Public Health Service (PHS) Act (42 U.S.C.
    254b), as amended.[^9] Describe where and how the bylaws, or if
    applicable, Articles of Incorporation (see Attachment 10) or
    Co-Applicant Agreement (if applicable, see Attachment 7)[^10]
    demonstrate that the applicant has an independent governing board
    that:

    a.  Is comprised of a majority (at least 51%) of individuals
        ("consumers") who are or will receive their primary care from
        the organization and who as a group, represent the individuals
        being served by the organization. Please reference Form 6-A in
        the response..

    b.  Meets at least once a month

    c.  Selects the services to be provided by the organization.

    d.  Schedules the hours during which such services will be provided.

    e.  Approves the health center's annual budget.

    f.  Approves applications for subsequent grants for the
        organization.

    g.  Approves the selection of a director (Program Director or CEO).

    h.  Establishes general policies for the organization, except in the
        case of a governing board of a public center.[^11]

2.  Applicant demonstrates that the structure of the Board is
    appropriate in terms of size, expertise, and representation of the
    service area and target populations served (e.g. appropriate
    racial/ethnic, gender representation, and where possible,
    socio-economic status and age). Applicants should reference Form 4:
    Community Characteristics as appropriate in the discussion of
    representation of the service area and target population.

3.  Applicant discusses the effectiveness of the board by describing how
    the governing board:

    a.  Operates including organization and responsibilities of Board
        committees. Examples of committees discussed may include
        Executive, Finance, Quality Assurance, Personnel, and Planning;

    b.  Monitors and evaluates the board's performance (e.g. process for
        addressing board weaknesses and challenges, communication,
        meeting documentation);

    c.  Measures and evaluates the organization's progress using data
        from the project's monitoring and evaluation activities, in
        meeting its annual and long-term programmatic and financial
        goals and plans for the long-range viability of the organization
        (e.g. strategic planning, ongoing review of organization's
        mission and bylaws, evaluating patient satisfaction, monitoring
        organization assets);

    d.  Provides board training, development and orientation for new
        members to ensure they have sufficient knowledge and information
        to make informed decisions regarding strategic direction,
        policies and financial position.

        []{#__RefHeading___Toc151519245 .anchor}**2. Review and
        Selection Process**

The Division of Independent Review is responsible for managing objective
reviews within HRSA. Applications competing for Federal funds receive an
objective and independent review performed by a committee of experts
qualified by training and experience in particular fields or disciplines
related to the program being reviewed. In selecting review committee
members, other factors in addition to training and experience may be
considered to improve the balance of the committee, e.g., geographic
distribution. Each reviewer is screened to avoid conflicts of interest
and is responsible for providing an objective, unbiased evaluation based
on the review criteria noted above. The committee provides expert advice
on the merits of each application to program officials responsible for
final selections for award.

Applications that pass the initial HRSA eligibility screening will be
reviewed and rated by a panel based on the program elements and review
criteria presented in relevant sections of this program announcement.
The review criteria are designed to enable the review panel to assess
the quality of a proposed project and determine the likelihood of its
success.  The criteria are closely related to each other and are
considered as a whole in judging the overall quality of an application.

[]{#Review_FundingPriority .anchor}**3. Anticipated Announcement and
Award Dates**

The successful recipients of the HRSA-08-112 funding opportunity will be
announced on or before April 1, 2008. The successful recipient of the
HRSA-08-113 funding opportunity will be announced on or before June 1,
2008.

[]{#__RefHeading___Toc151519248 .anchor}**VI. Award Administration
Information**

[]{#__RefHeading___Toc151519249 .anchor}**1. Award Notices**

Each applicant will receive written notification of the outcome of the
objective review process, including a summary of the expert committee's
assessment of the application's merits and weaknesses, and whether the
application was selected for funding. Applicants who are selected for
funding may be required to respond in a satisfactory manner to
Conditions placed on their application before funding can proceed.
Letters of notification do not provide authorization to begin
performance.

The Notice of Grant Award sets forth the amount of funds granted, the
terms and conditions of the grant, the effective date of the grant, the
budget period for which initial support will be given, the non-Federal
share to be provided (if applicable), and the total project period for
which support is contemplated. Signed by the Grants Management Officer,
it is sent to the applicant agency's Authorized Representative, and
reflects the only authorizing document.

[]{#__RefHeading___Toc151519250 .anchor}**2. Administrative and National
Policy Requirements**

Successful applicants and their subrecipients must comply with the
administrative requirements outlined in 45 CFR Part 74
(non-governmental) or 45 CFR Part 92 (governmental), as appropriate.

HRSA grant awards are subject to the requirements of the HHS Grants
Policy Statement (HHS GPS) that are applicable to the grant based on
recipient type and purpose of award. This includes, as applicable, any
requirements in Parts I and II of the HHS GPS that apply to the award,
as well as any requirements of Part IV. The HHS GPS is available at
<http://www.hrsa.gov/grants/>. The general terms and conditions in the
HHS GPS will apply as indicated unless there are statutory, regulatory,
or award-specific requirements to the contrary (as specified in the
Notice of Award).

**PUBLIC POLICY ISSUANCE**

**HEALTHY PEOPLE 2010**

**Healthy People 2010** is a national initiative led by HHS that sets
priorities for all HRSA programs. The initiative has two major goals:
(1) To increase the quality and years of a healthy life; and (2)
Eliminate our country's health disparities. The program consists of 28
focus areas and 467 objectives. HRSA has actively participated in the
work groups of all the focus areas, and is committed to the achievement
of the Healthy People 2010 goals.

Applicants must summarize the relationship of their projects and
identify which of their programs objectives and/or sub-objectives relate
to the goals of the Healthy People 2010 initiative.

Copies of the Healthy People 2010 may be obtained from the
Superintendent of Documents or downloaded at the Healthy People 2010
website: [http://www.health.gov/healthypeople/document]{.underline}/.

The Public Health Service strongly encourages all award recipients to
provide a smoke-free workplace and to promote the non-use of all tobacco
products. Further, Public Law 103-227, the Pro-Children Act of 1994,
prohibits smoking in certain facilities (or in some cases, any portion
of a facility) in which regular or routine education, library, day care,
health care or early childhood development services are provided to
children.

[]{#__RefHeading___Toc151519253 .anchor}**3. Reporting**

The successful applicant under this guidance must comply with the
following reporting and review activities:

a.  **Audit Requirements**

> Comply with audit requirements of Office of Management and Budget
> (OMB) Circular A-133. Information on the scope, frequency, and other
> aspects of the audits can be found on the Internet at
> [www.whitehouse.gov/omb/circulars](http://www.whitehouse.gov/omb/circulars);

b.  **Payment Management Requirements**

> Submit a quarterly electronic PSC-272 via the Payment Management
> System. The report identifies cash expenditures against the authorized
> funds for the grant. Failure to submit the report may result in the
> inability to access grant funds. The PSC-272 Certification page should
> be faxed to the PMS contact at the fax number listed on the 272 form,
> or it may be submitted to the:
>
> Division of Payment Management
>
> HHS/ASAM/PSC/FMS/DPM
>
> PO Box 6021
>
> Rockville, MD 20852
>
> Telephone: (877) 614-5533;

c.  **Status Reports**

> 1**.** Submit a **Financial Status Report**. A financial status report
> is required within 90 days of the end of each grant year. The report
> is an accounting of expenditures under the project that year;
>
> 2\. Submit a **Uniform Data System Report**. All grantees will be
> expected to submit a Universal Report and Grant Report (if applicable)
> annually for the Uniform Data System (UDS). This report provides data
> on services, staffing and financing across all section 330 health
> centers. The UDS is an integrated reporting system used to collect
> data annually on its programs to ensure compliance with legislative
> mandates and to report to Congress, OMB, and other policy makers on
> program accomplishments.
>
> **d. Performance Review**
>
> HRSA's Office of Performance Review (OPR) serves as the agency's focal
> point for reviewing and enhancing the performance of HRSA funded
> programs within communities and States. As part of this agency-wide
> effort, HRSA grantees will be required to participate, where
> appropriate, in an on-site performance review of their HRSA funded
> program(s) by a review team from one of the ten OPR regional
> divisions. Grantees should expect to participate in a performance
> review at some point during their project period. When a grantee
> receives more than one HRSA grant, each of the grantee's HRSA funded
> programs will be reviewed during the same performance review.
>
> The purpose of performance review is to improve the performance of
> HRSA funded programs. Through systematic pre-site and on-site
> analysis, OPR works collaboratively with grantees and HRSA
> Bureaus/Offices to measure program performance, analyze the factors
> impacting performance, and identify effective strategies and
> partnerships to improve program performance, with a particular focus
> on outcomes. Upon completion of the performance review, grantees will
> be required to prepare an Action Plan that identifies key actions to
> improve program performance as well as addresses any identified
> program requirement issues. In addition, performance reviews also
> provide an opportunity for grantees to offer direct feedback to the
> agency about the impact of HRSA policies on program implementation and
> performance within communities and States.
>
> For additional information on performance reviews, please visit:
> <http://www.hrsa.gov/performancereview>.

[]{#__RefHeading___Toc151519254 .anchor}**VII. Agency Contacts**

Applicants may obtain additional information regarding business,
administrative, or fiscal issues related to this grant announcement by
contacting:

Donna M. Marx

Health Services Branch

HRSA Division of Grants Management Operations

Parklawn Building, Room 11A-02

5600 Fishers Lane

Rockville, MD 20857

Telephone: 301-594-4245

Fax: 301-443-6686

Email: dmarx@hrsa.gov

Technical assistance regarding this funding announcement may be obtained
by contacting:

> Nicole Amado
>
> Public Health Analyst
>
> Office of Policy and Program Development
>
> Parklawn Building, Room 17C-20
>
> 5600 Fishers Lane
>
> Rockville, MD 20857
>
> Telephone: 301-594-4300
>
> Fax: 301-480-7225
>
> Email: namado@hrsa.gov

Technical Assistance Resources:
[www.hrsa.gov/grants/technicalassistance/sac.htm](http://www.hrsa.gov/grants/technicalassistance/sac.htm)

[]{#__RefHeading___Toc151519255 .anchor}**VIII. Other Information**

## Federal Tort Claims Act Coverage/Medical Malpractice Insurance

Organizations that receive grant funds under section 330 are eligible
for protection from suits alleging medical malpractice through the
Federally Supported Health Centers Assistance Act of 1992 (Act).  The
Act provides that health center employees may be deemed Federal
employees and be afforded the protections of the Federal Tort Claims Act
(FTCA). 

**There is a new process for submitting FTCA deeming applications.**
Please reference Program Assistance Letter 2007-02: Updated Application
Submission Instructions for FTCA Deeming Under the Federally Supported
Health Centers Assistance Act for Calendar Year 2008 available at
<http://bphc.hrsa.gov/policy/pal0702.htm>.

Organizations should be aware that participation in the FTCA program is
[not guaranteed]{.underline}. If an applicant is not absolutely certain
it can meet the requirements of the Act, the costs associated with the
purchase of malpractice insurance should be included in the proposed
budget. The search for malpractice insurance, if necessary, should begin
as soon as possible. All applicants will need to submit a new
application annually to be deemed.  Applicants are encouraged to review
PIN 99-08: Health Centers and the Federal Tort Claims Act (Signed April
12, 1999), and contact the toll free hotline 866-FTCA-HELP
(866-382-2435) if they have additional questions.

## 340B Drug Pricing Program

The 340B Drug Pricing Program resulted from enactment of Public Law
102-585, the [Veterans Health Care Act of
1992](http://www.hrsa.gov/opa/pl102585.htm), which is codified as
Section 340B of the Public Health Service Act, as amended.  The program
limits the cost of covered outpatient drugs to certain federal grantees,
federally-qualified health center look-alikes and qualified
disproportionate share hospitals. Covered entities may realize a cost
savings of 20 -50 percent on outpatient drug purchases and additional
savings on outpatient drugs and other value added products through
participation in the 340B Prime Vendor Program (PVP).  Pharmacy related
technical assistance is available at 866-PharmTA (866-742-7682).  There
is no cost to participate in the 340B program or the 340B Prime Vendor
Program and eligible entities are not required to have an established
in-house pharmacy to participate.  For additional information, please
contact the Office of Pharmacy Affairs (OPA) at 800-628-6297 or visit
the OPA website at <http://www.hrsa.gov/opa/>.

***Technical Assistance Conference Call***

The Bureau of Primary Health Care will announce a pre-applicant
technical assistance conference call shortly after the guidance release
date. Please visit
[www.hrsa.gov/grants/technicalassistance/sac.htm](http://www.hrsa.gov/grants/technicalassistance/sac.htm)
for the call date and additional resources.

[]{#__RefHeading___Toc151519258 .anchor}**IX. Tips for Writing a Strong
Application**

**Include DUNS Number.** You must include a DUNS Number to have your
application reviewed. Applications ***will not*** be reviewed without a
DUNS number. To obtain a DUNS number, access
[www.dunandbradstreet.com](http://www.dunandbradstreet.com/) or call
1-866-705-5711. Please include the DUNS number in item 8c on the
application face page.

**Keep your audience in mind.** Reviewers will use only the information
contained in the application to assess the application. Be sure the
application and responses to the program requirements and expectations
are complete and clearly written. Do not assume that reviewers are
familiar with the applicant organization, service area, barriers to
health care, or health care needs in your community. Keep the review
criteria in mind when writing the application.

**Start preparing the application early.** Allow plenty of time to
gather required information from various sources.

**Follow the instructions in this guidance carefully.** Place all
information in the order requested in the guidance. Avoid the risk of
having reviewers hunt through your application for information.

**Be brief, concise, and clear.** Make your points understandable.
Provide accurate and honest information, including candid accounts of
problems and realistic plans to address them. If any required
information or data is omitted, explain why. Make sure the information
provided in each table, chart, attachment, etc., is consistent with the
proposal narrative and information in other tables. Your budget should
reflect back to the proposed activities, and all forms should be filled
in accurately and completely.

**Be organized and logical.** Many applications fail to receive a high
score because the reviewers cannot follow the thought process of the
applicant or because parts of the application do not fit together.

**Be careful in the use of attachments.** Do not use the attachments for
information that is required in the body of the application. Be sure to
cross-reference all tables and attachments to the appropriate text in
the application. Be sure to upload the attachments in the order
indicated in the forms.

**Carefully proofread the application.** Misspellings and grammatical
errors will impede reviewers in understanding the application. Be sure
that page limits are followed. Limit the use of abbreviations and
acronyms, and define each one at its first use and periodically
throughout application. Make sure you submit your application in final
form, without markups.

**Print out and carefully review an electronic application to ensure
accuracy and completion.** When submitting electronically, print out the
application before submitting it to ensure appropriate formatting and
adherence to page limit requirements. **Check to ensure that all
attachments are included before sending the application forward.**

**Ensure that all information is submitted at the same time. We will not
consider additional information and/or materials submitted after your
initial submission, nor will we accept e-mailed applications or
supplemental materials once your application has been received.**

# APPENDIX A: HRSA's Electronic Submission User Guide

User Guide Table of Contents

> 1\. INTRODUCTION
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 1.1. DOCUMENT PURPOSE AND
> SCOPE\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 1.2. DOCUMENT ORGANIZATION AND VERSION
> CONTROL\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 2\. NONCOMPETING CONTINUATION
> APPLICATION\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 2.1. PROCESS
> OVERVIEW\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 2.2. GRANTEE ORGANIZATION NEEDS TO REGISTER WITH
> [[GRANTS.GOV]{.underline}](http://GRANTS.GOV/) (IF NOT ALREADY
> REGISTERED)...................................................................................................\...\...\...\...\...
>
> 2.3. PROJECT DIRECTOR AND AUTHORIZING OFFICIAL NEED TO REGISTER WITH
> HRSA EHBS
>
> (IF NOT ALREADY REGISTERED)
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 2.4. APPLY THROUGH [[GRANTS.GOV]{.underline}](http://GRANTS.GOV/)
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 2.4.1 Find Funding
> Opportunity\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 2.4.2 Download Application Package
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 2.4.3 Complete
> Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 2.4.4 Submit
> Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 2.4.5 Verify Status of Application
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 2.5. VERIFY IN HRSA ELECTRONIC HANDBOOKS
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 2.5.1 Verify Status of Application
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 2.5.2 Manage Access to Your Application
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 2.5.3 Check Validation
> Errors\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 2.5.4 Fix Errors and Complete
> Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 2.5.5 Submit
> Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 3\. COMPETING
> APPLICATION\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 3.1. PROCESS
> OVERVIEW\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 3.2. GRANTEE ORGANIZATION NEEDS TO REGISTER WITH
> [[GRANTS.GOV]{.underline}](http://GRANTS.GOV/) NOT ALREADY
> REGISTERED)\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 3.3. APPLY THROUGH
> [[GRANTS.GOV]{.underline}](http://GRANTS.GOV/)\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 3.3.1 Find Funding
> Opportunity\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 3.3.2 Download Application
> Package\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 3.3.3 Complete
> Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 3.3.4 Submit
> Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 3.3.5 Verify Status of Application
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 4\. GENERAL INSTRUCTIONS FOR APPLICATION
> SUBMISSION\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 4.1. NARRATIVE ATTACHMENT
> GUIDELINES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 4.1.1
> Font\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 4.1.2 Paper Size and
> Margins\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 4.1.3
> Names\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 4.1.4 Section Headings
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 4.1.5 Page
> Numbering\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 4.1.6 Allowable Attachment or Document
> Types\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 4.2. APPLICATION CONTENT ORDER (TABLE OF
> CONTENTS)\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 4.3. PAGE
> LIMIT\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 5.0 CUSTOMER SUPPORT INFORMATION
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 5.1.1 Grants.gov Customer
> Support\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 5.1.2 HRSA Call
> Center\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 5.1.3 HRSA Program
> Support\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 6.0
> FAQs\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 6.1.
> SOFTWARE\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 6.1.1 What are the software requirements for using
> Grants.gov?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 6.1.2 Why can\'t I download PureEdge Viewer onto my
> machine?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 6.1.3 I have heard that Grants.gov is not Macintosh compatible. What
> do I do if I use only a
> Macintosh?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
> \...\...\...\...\...\...\.....
>
> 6.1.4 What are the software requirements for HRSA
> EHBs?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 6.1.5 What are the system requirements for using HRSA EHBs on a
> Macintosh computer?\...\...\...\...\...\...\....
>
> 6.2. APPLICATION RECEIPT
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...

6.2.1 What will be the receipt date\--the date the application is
stamped as received by Grants.gov

> or the date the data is received by HRSA?
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 6.2.2 When do I need to submit my application?
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 6.2.3 What emails can I expect once I submit my application? Is email
> reliable? \...\...\...\...\...\...\...\...\...\...\...\...\...
>
> 6.2.4 If a resubmission is required because of Grants.gov system
> problems, will these be
>
> considered
> \"late\"?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....
>
> 6.3. APPLICATION
> SUBMISSION\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....

6.3.1 How can I make sure that my electronic application is presented in
the right order for

> objective
> review?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....
>
> 6.4 GRANT.GOV
> HELP\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....

# 1. Introduction

## 1.1 Document Purpose and Scope {#document-purpose-and-scope .unnumbered}

Major changes are coming to HRSA's Grant Application Process. For
guidances released/posted on or after January 1, 2006, HRSA will no
longer accept applications for grant opportunities on paper. Applicants
submitting new and competing continuations and a selected number of
noncompeting continuation applications will be required to submit
electronically through Grants.gov. All applicants must submit in this
manner unless the applicant is granted a written exemption from this
requirement in advance by the Director of HRSA's Division of Grants
Policy.

The purpose of this document is to provide detailed instructions to help
applicants and grantees submit applications electronically to HRSA
through Grants.gov. The document is intended to be the comprehensive
source of all information related to the new processes that HRSA and its
customers have to adopt and will be updated periodically. This document
is not meant to replace program guidance documents for funding
announcements.

## 1.2 Document Organization and Version Control {#document-organization-and-version-control .unnumbered}

This document contains 5 sections apart from the Introduction. Following
is the summary:

  ------------------------------ ----------------------------------------
  **Section**                    **Description**

  Noncompeting Continuation      Provides detailed instructions to
  Application                    existing HRSA grantees for applying
                                 electronically using Grants.gov for all
                                 noncompeting announcements

  Competing Application          Provides detailed instructions to
                                 applicant organizations for applying
                                 electronically using Grants.gov for all
                                 competing announcements

  General Instructions for       Provides instructions and important
  Application Submission         policy guidance on application format
                                 requirements

  Customer Support Information   Provides contact information to address
                                 technical and programmatic questions

  Frequently Asked Questions     Provides answers to frequently asked
  (FAQs)                         questions by various categories
  ------------------------------ ----------------------------------------

This document is under version control. Please visit
<http://www.hrsa.gov/grants> to retrieve the latest published version.

# 2. Noncompeting Continuation Application

## 2.1 Process Overview {#process-overview .unnumbered}

Following is the process for submitting a noncompeting continuation
application through Grants.gov:

1.  HRSA will communicate noncompeting announcement number to the
    project director (PD) and authorizing official (AO) via email. The
    announcement number will be required to search for the announcement
    in Grants.gov.

2.  Search for the announcement in Grants.gov Apply
    (<http://www.grants.gov/Apply>).

3.  Download the application package and instructions from Grants.gov.
    The program guidance is also part of the instructions that must be
    downloaded.

4.  Save a local copy of the application package on your computer and
    complete all the forms based on the instructions provided in the
    program guidance.

5.  Submit the application package through Grants.gov. (Requires
    registration)

6.  Track the status of your submitted application at Grants.gov until
    you receive a notification from Grants.gov that your application has
    been received by HRSA.

7.  HRSA Electronic Handbooks (EHBs) software pulls the application
    information into EHBs and validates the data against HRSA's business
    rules.

8.  HRSA notifies the project director, authorizing official, business
    official (BO) and application point of contact (POC) by email to
    check HRSA EHBs for results of HRSA validations and enter additional
    information, including in some cases performance measures, necessary
    to process the noncompeting continuation.

9.  AO verifies the application in HRSA EHBs, fixes any validation
    errors, makes necessary corrections and submits the application to
    HRSA. (Requires registration)

## 2.2 Grantee Organization Needs to Register With Grants.gov (if not already registered) -- See Appendix B {#grantee-organization-needs-to-register-with-grants.gov-if-not-already-registered-see-appendix-b .unnumbered}

Grants.gov requires a **one-time** registration by the applicant
organization. This is a three step process and should be completed by
any organization wishing to apply for grant. If you do not complete this
registration process you will not be able to submit an application. The
registration process will require some time (anywhere from 5 business
days to a month). Therefore, applicants or those considering applying at
some point in the future should register immediately. Registration with
Grants.gov provides the individuals from the organization the required
credentials in order to apply.

If an applicant organization has already completed Grants.gov
registration for another Federal agency, this section can be skipped.

For those applicant organizations still needing to register with
Grants.gov, registration information can be found on the Grants.gov Get
Started website (<http://www.grants.gov/GetStarted>). To be able to
successfully register in Grants.gov, it is necessary that you complete
all of the following required actions:

-   Obtain an organizational Data Universal Number System (DUNS) number

-   Register the organization with Central Contractor Registry (CCR)

-   Identify the organization's E-Business POC (Point of Contact)

-   Confirm the organization's CCR "Marketing Partner ID Number (M-PIN)"
    password

-   Register an Authorized Organization Representative (AOR)

```{=html}
<!-- -->
```
-   Obtain a username and password from the Grants.gov Credential
    Provider

-   Register the username and password with Grants.gov

-   Get authorized as an AOR by your organization

In addition, if an applicant does not have a Taxpayer Identification
Number (TIN) or Employer Identification Number (EIN), allow for extra
time. Beginning Oct. 30, 2005, the CCR also validates the EIN against
Internal Revenue Service records, a step that will take one to two
business days.

Please direct questions regarding Grants.gov registration to the
Grants.gov Contact Center at Tel.: 1-800-518-4726. Contact Center hours
of operation are Monday-Friday from 7:00 a.m. to 9:00 p.m. Eastern Time,
excluding Federal holidays.

-   It is recommended that this registration process be completed at
    least two weeks prior to the submittal date of your organization's
    first Grants.gov submission.

## 2.3 Project Director and Authorizing Official Need to Register with HRSA EHBs (if not already registered) {#project-director-and-authorizing-official-need-to-register-with-hrsa-ehbs-if-not-already-registered .unnumbered}

In order to access your noncompeting continuation application in HRSA
EHBs, existing grantee organizations must register within the EHBs. The
purpose of the registration process is to collect consistent information
from all users, avoid collection of redundant information and allow for
the unique identification of each system user. Note that registration
within HRSA EHBs is required only **once for each user for each
organization they represent.**

Registration within HRSA EHBs is a two-step process. In the first step,
individual users from an organization who participate in the grants
process such as applying for noncompeting continuations must create
**individual** system accounts. In the second step, the users must
associate themselves with the appropriate grantee organization. **To
find your organization record use the 10-digit grant number from the
Notice of Grant Award (NGA) belonging to your grant.** Note that since
all existing grantee organization records already exist within EHBs,
there is no need to create a new one.

To complete the registration quickly and efficiently we recommend that
you have the following information handy:

1.  Identify your role in the grants management process. HRSA EHBs offer
    the following three functional roles for individuals from
    applicant/grantee organizations:

-   Authorizing Official (AO),

-   Business Official (BO), and

-   Other Employee (for project directors, assistant staff, AO designees
    and others).

For more information on functional responsibilities refer to the HRSA
EHBs online help.

2.  10-digit grant number from the latest NGA belonging to your grant
    (Box 4b on NGA). You must use the grant number to find your
    organization during registration. All individuals from the
    organization working on the grant must use the same grant number to
    ensure correct registration.

In order to access the noncompeting application, the project director
and other participants have to register the specific grant and add it to
their respective portfolios. This step is required to ensure that only
the authorized individuals from the organization have access to grant
data. **Project directors will need the last released NGA in order to
complete this additional step**. Again, note that this is a one time
requirement.

The project director must give the necessary privileges to the
authorizing official and other individuals who will assist in the
noncompeting continuation application submission using the administer
feature in the grant handbook. The project director should also delegate
the "Administer Grant Users" privilege to the authorizing official.

Once you have access to your grant handbook, use the "Noncompeting
Continuations" link under the deliverables section to access your
noncompeting application.

Note that registration with HRSA EHBs is independent of Grants.gov
registration.

For assistance in registering with HRSA EHBs, call 877-GO4-HRSA
(877-464-4772) between 9:00 am to 5:30 pm ET or email
<callcenter@hrsa.gov>.

-   You must use your 10-digit grant number (box 4b from NGA) to
    identify your organization.

## 2.4 Apply through Grants.gov {#apply-through-grants.gov .unnumbered}

### 2.4.1 Find Funding Opportunity {#find-funding-opportunity .unnumbered}

Search for the announcement in Grants.gov **Apply**
(<http://www.grants.gov/Apply>).

Enter the announcement number communicated to you in the field *Funding
Opportunity Number*. (Example announcement number: 5-S45-06-001)

-   Noncompeting announcements are not available in Grants.gov FIND!

### 2.4.2 Download Application Package {#download-application-package .unnumbered}

Download the application package and instructions. In order to view
application package and instructions, you will also need to download and
install the PureEdge Viewer (<http://www.grants.gov/DownloadViewer>).
This small, free program will allow you to access, complete, and submit
applications electronically and securely.

-   Please review the system requirements for PureEdge Viewer on the
    Grants.gov website.

### 2.4.3 Complete Application {#complete-application .unnumbered}

Complete the application using both the built-in instructions and the
instructions provided in the program guidance. Ensure that you save a
copy of the application on your local computer.

-   Ensure that you provide your 10-digit grant number (box 4b from NGA)
    in the Federal Award Identifier field (box 5b in SF424 or box 4 in
    SF424 R&R)

Please direct questions regarding PureEdge to Grants.gov. Contact the
Grants.gov Contact Center at Tel.: 1-800-518-4726. Contact Center hours
of operation are Monday-Friday from 7:00 a.m. to 9:00 p.m. Eastern Time,
excluding Federal holidays.

For assistance with program guidance related questions, please contact
the program contact listed on the program guidance.

-   You can complete the application offline -- you do not have to be
    connected to the Internet.

### 2.4.4 Submit Application {#submit-application .unnumbered}

The \"Submit\" button on the application package cover page will become
active after you have downloaded the application package, completed all
required forms, attached all required documents, and saved your
application package. Click on the \"Submit\" button once you have done
all these things and you are ready to send your completed application to
Grants.gov.

Review the provided application summary to confirm that the application
will be submitted to the program you wish to apply for. To submit, you
will be asked to Log into Grants.gov. Once you have logged in, your
application package will automatically be uploaded to Grants.gov. A
confirmation screen will appear once the upload is complete. Note that a
Grants.gov Tracking number will be provided on this screen. Please
record this number so that you may refer to it for all subsequent help.

Please direct questions regarding application submission to the
Grants.gov Contact Center at Tel.: 1-800-518-4726. Contact Center hours
of operation are Monday-Friday from 7:00 a.m. to 9:00 p.m. Eastern Time,
excluding Federal holidays.

-   You must be connected to the Internet and must have a Grants.gov
    username and password to submit the application package.

### 2.4.5 Verify Status of Application {#verify-status-of-application .unnumbered}

Once Grants.gov has received your submission, Grants.gov will send email
messages to advise you of the progress of your application through the
system. Over the next 24 to 48 hours, you should receive two emails. The
first will confirm receipt of your application by the Grants.gov system
("Received"), and the second will indicate that the application has
either been successfully validated ("Validated") by the system prior to
transmission to the grantor agency or has been rejected due to errors
("Rejected with Errors").

In case of any errors, you must correct the application and resubmit it
to Grants.gov. If you are unable to resubmit because the opportunity has
since closed, **contact the HRSA Call Center** at 877-GO4-HRSA
(877-464-4772) between 9:00 am to 5:30 pm ET or email
<callcenter@hrsa.gov>. You may be asked to provide a copy of the
"Rejected with Errors" notification you received from Grants.gov.

You can check the status of your application(s) anytime after
submission, by logging into Grants.gov using the black \'Applicants\'
link at the top of any page, and clicking on the \'Check Application
Status\' link.

If there are no errors, the application will be downloaded by HRSA. On
successful download at HRSA, the status of the application will change
to "Received by Agency" and you will receive an additional email from
Grants.gov. Subsequently within two to three business days the status
will change to "Agency Tracking Number Assigned."

-   It is recommended that you check the status of your application in
    Grants.gov until the status is changed to "Agency Tracking Number
    Assigned".

## 2.5 Verify in HRSA Electronic Handbooks {#verify-in-hrsa-electronic-handbooks .unnumbered}

For assistance in registering with or using HRSA EHBs, call 877-GO4-HRSA
(877-464-4772) between 9:00 am to 5:30 pm ET or email
<callcenter@hrsa.gov>.

-   Grant Project Director must be registered in HRSA EHBs and have
    access to the specific grant for which the noncompeting application
    is being submitted for further actions.

### 2.5.1 Verify Status of Application {#verify-status-of-application-1 .unnumbered}

Once your application is received by HRSA, it will be processed to
ensure that the application is submitted for the correct funding
announcement, with the correct grant number and grantee organization.
Upon this processing, which is expected to take up to two to three
business days, HRSA will assign a unique tracking number to your
application. This tracking number will be posted to Grants.gov and the
status of your application will be changed to "Agency Tracking Number
Assigned". Note the HRSA tracking number and use it for all
correspondence with HRSA. At this point, your application is ready for
review and submission in HRSA EHBs.

You should also receive an email from HRSA EHBs confirming the
successful receipt of your application at HRSA. The email is sent to the
project director, authorizing official, point of contact for the
application and the business official -- all from the submitted
application. The email is also sent to the current project director
listed on the NGA. Because email is not always reliable, please check
the HRSA EHBs or Grants.gov to see if the application is available for
review in HRSA EHBs.

-   Because email is not reliable, check HRSA EHBs within two to three
    business days from submission within Grants.gov for availability of
    your application.

### 2.5.2 Manage Access to Your Application {#manage-access-to-your-application .unnumbered}

You must be registered in HRSA EHBs to get access to your application.
To ensure that only the right individuals from the organization get
access to the application, you must follow the process described
earlier.

The project director, using the Administer feature in the grant
handbook, must give the necessary privileges to the authorizing official
and other individuals who will assist in the submission of the
noncompeting continuation application. Project directors must also
delegate the "Administer Grant Users" privilege to the authorizing
official so that future administration can be managed by the authorizing
official.

Once you have access to your grant handbook, use the "Noncompeting
Continuations" link under the deliverables section to access your
noncompeting application.

### 2.5.3 Check Validation Errors {#check-validation-errors .unnumbered}

HRSA EHBs will apply HRSA's business rules to the application received
through Grants.gov. All validation errors are recorded and displayed to
the applicant. To view the validation errors use the 'Grants.gov Data
Validation Comments' link on the application status page in HRSA EHBs.

### 2.5.4 Fix Errors and Complete Application {#fix-errors-and-complete-application .unnumbered}

Applicants must review the errors in HRSA EHBs and make necessary
changes. Applicants must also complete the detailed budget and other
required forms in HRSA EHBs and assign an AO registered in HRSA EHBs to
the application. HRSA EHBs will show the status of each form in the
application package and all forms must be complete before submission.

### 2.5.5 Submit Application {#submit-application-1 .unnumbered}

To submit an application, you must have the 'Submit Noncompeting
Continuation' privilege. This privilege must be given by the project
director to the authorizing official or a designee. Once all forms are
complete, the application can be submitted to HRSA.

-   You will have two weeks from the date the application was due in
    Grants.gov for submission of the remaining information in HRSA EHBs.
    The new due date will be listed in HRSA EHBs.

-   Face page must be printed from HRSA EHBs and not from Grants.gov
    application.

# 3. Competing Application

## 3.1 Process Overview {#process-overview-1 .unnumbered}

Following is the process for submitting a competing application through
Grants.gov:

1\. HRSA will post all competing announcements on Grants.gov FIND
(<http://grants.gov/search/>). Announcements are typically posted at the
beginning of the fiscal year when HRSA releases its annual Preview,
although program guidances are generally not available until later. For
more information visit <http://www.hrsa.gov/grants>.

2\. When program guidance is available, search for the announcement in
Grants.gov Apply (<http://www.grants.gov/Apply>).

3\. Download the application package and instructions from Grants.gov.
The program guidance is also part of the instructions that must be
downloaded.

4\. Save a local copy of the application package on your computer and
complete all the forms based on the instructions provided in the program
guidance.

5\. Submit the application package through Grants.gov. (Requires
registration)

6\. Track the status of your submitted application at Grants.gov until
you receive a notification from Grants.gov that your application has
been received by HRSA.

## 3.2 Grantee Organization Needs to Register With Grants.gov (if not already registered) -- See Appendix B {#grantee-organization-needs-to-register-with-grants.gov-if-not-already-registered-see-appendix-b-1 .unnumbered}

Grants.gov requires a **one-time** registration by the applicant
organization. This is a three step process and should be completed by
any organization wishing to apply for grant. If you do not complete this
registration process you will not be able to submit an application. The
registration process will require some time (anywhere from 5 business
days to a month). Therefore, applicants or those considering applying at
some point in the future should register immediately. Registration with
Grants.gov provides the individuals from the organization the required
credentials in order to apply.

If an applicant organization has already completed Grants.gov
registration for another Federal agency, this section can be skipped.

For those applicant organizations still needing to register with
Grants.gov, registration information can be found on the Grants.gov Get
Started website (<http://www.grants.gov/GetStarted>). To be able to
successfully register in Grants.gov, it is necessary that you complete
all of the following required actions:

-   Obtain an organizational Data Universal Number System (DUNS) number

-   Register the organization with Central Contractor Registry (CCR)

-   Identify the organization's E-Business POC (Point of Contact)

-   Confirm the organization's CCR "Marketing Partner ID Number (M-PIN)"
    password

-   Register an Authorized Organization Representative (AOR)

```{=html}
<!-- -->
```
-   Obtain a username and password from the Grants.gov Credential
    Provider

-   Register the username and password with Grants.gov

-   Get authorized as an AOR by your organization

In addition, if an applicant does not have a Taxpayer Identification
Number (TIN) or Employer Identification Number (EIN), allow for extra
time. Beginning Oct. 30, 2005, the CCR also validates the EIN against
Internal Revenue Service records, a step that will take one to two
business days.

Please direct questions regarding Grants.gov registration to the
Grants.gov Contact Center at Tel.: 1-800-518-4726. Contact Center hours
of operation are Monday-Friday from 7:00 a.m. to 9:00 p.m. Eastern Time,
excluding Federal holidays.

-   It is recommended that this registration process be completed at
    least two weeks prior to the submittal date of your organization's
    first Grants.gov submission.

## 3.3 Apply through Grants.gov {#apply-through-grants.gov-1 .unnumbered}

### 3.3.1 Find Funding Opportunity {#find-funding-opportunity-1 .unnumbered}

Search for announcements in Grants.gov **FIND**
(<http://grants.gov/search/>) and select the announcement that you wish
to apply for. Refer to the program guidance for eligibility criteria.

Please visit <http://www.hrsa.gov/grants> to read annual HRSA Preview.

-   All competing announcements should be available in Grants.gov FIND!
    When program guidance is release, announcements are made available
    in Grants.gov APPLY.

### 3.3.2 Download Application Package {#download-application-package-1 .unnumbered}

Download the application package and instructions. In order to view
application package and instructions, you will also need to download and
install the PureEdge Viewer (<http://www.grants.gov/DownloadViewer>).
This small, free program will allow you to access, complete, and submit
applications electronically and securely.

-   Please review the system requirements for PureEdge Viewer on the
    Grants.gov website.

### 3.3.3 Complete Application {#complete-application-1 .unnumbered}

Complete the application using both the built-in instructions and the
instructions provided in the program guidance. Ensure that you save a
copy of the application on your local computer.

-   If you are applying for a competing continuation or a supplemental
    grant, ensure that you provide your 10-digit grant number (box 4b
    from NGA) in the Federal Award Identifier field (box 5b in SF424 or
    box 4 in SF424 R&R)

Please direct questions regarding PureEdge to Grants.gov. Contact the
Grants.gov Contact Center at Tel.: 1-800-518-4726. Contact Center hours
of operation are Monday-Friday from 7:00 a.m. to 9:00 p.m. Eastern Time,
excluding Federal holidays.

For assistance with program guidance related questions, please contact
the program contact listed on the program guidance.

-   You can complete the application offline -- you do not have to be
    connected to the Internet.

### 3.3.4 Submit Application {#submit-application-2 .unnumbered}

The \"Submit\" button on the application package cover page will become
active after you have downloaded the application package, completed all
required forms, attached all required documents, and saved your
application package. Click on the \"Submit\" button once you have done
all these things and you are ready to send your completed application to
Grants.gov.

Review the provided application summary to confirm that the application
will be submitted to the program you wish to apply for. To submit, you
will be asked to Log into Grants.gov. Once you have logged in, your
application package will automatically be uploaded to Grants.gov. A
confirmation screen will appear once the upload is complete. Note that a
Grants.gov Tracking number will be provided on this screen. Please
record this number so that you may refer to it for all subsequent help.

Please direct questions regarding application submission to the
Grants.gov Contact Center at Tel.: 1-800-518-4726. Contact Center hours
of operation are Monday-Friday from 7:00 a.m. to 9:00 p.m. Eastern Time,
excluding Federal holidays.

-   You must be connected to the Internet and must have a Grants.gov
    username and password to submit the application package.

### 3.3.5 Verify Status of Application {#verify-status-of-application-2 .unnumbered}

Once Grants.gov has received your submission, Grants.gov will send email
messages to advise you of the progress of your application through the
system. Over the next 24 to 48 hours, you should receive two emails. The
first will confirm receipt of your application by the Grants.gov system
("Received"), and the second will indicate that the application has
either been successfully validated ("Validated") by the system prior to
transmission to the grantor agency or has been rejected due to errors
("Rejected with Errors").

In case of any errors, you must correct the application and resubmit it
to Grants.gov. If you are unable to resubmit because the opportunity has
since closed, **contact the Director of the Division of Grants Policy**
via email at <DGPWaivers@hrsa.gov> and thoroughly explain the situation;
include a copy of the "Rejected with Errors" notification.

You can check the status of your application(s) anytime after
submission, by logging into Grants.gov using the black \'Applicants\'
link at the top of any page, and clicking on the \'Check Application
Status\' link.

If there are no errors, the application will be downloaded by HRSA. On
successful download at HRSA, the status of the application will change
to "Received by Agency" and you will receive an additional email from
Grants.gov.

Once your application is received by HRSA, it will be processed to
ensure that the application is submitted for the correct funding
announcement, with the correct grant number (if applicable), and
applicant/grantee organization. Upon this processing, which is expected
to take up to two to three business days, HRSA will assign a unique
tracking number to your application. This tracking number will be posted
to the Grants.gov and the status of your application will be changed to
"Agency Tracking Number Assigned". Note the HRSA tracking number and use
it for all correspondence with HRSA.

-   It is recommended that you check the status of your application in
    Grants.gov until the status is changed to "Agency Tracking Number
    Assigned".

# 4. General Instructions for Application Submission

-   It is mandatory to follow the instructions provided in this section
    to ensure that your application can be printed efficiently and
    consistently for review.

-   

-   Failure to follow the instructions may make your application
    non-compliant. Non-compliant applications will not be given any
    consideration and the particular applicants will be notified.

## 4.1 Narrative Attachment Guidelines {#narrative-attachment-guidelines .unnumbered}

-   The following guidelines are applicable to both electronic and paper
    submissions (when allowed) unless otherwise noted.

### 4.1.1 Font  {#font .unnumbered}

Please use an easily readable serif typeface, such as Times Roman,
Courier, or CG Times. The text and table portions of the application
must be submitted in not less than 12 point and 1.0 line spacing.
Applications not adhering to 12 point font requirements may be returned.
Do not use colored, oversized or folded materials. For charts, graphs,
footnotes, and budget tables, applicants may use a different pitch or
size font, not less than 10 pitch or size font. However, it is vital
that when scanned and/or reproduced, the charts are still clear and
readable.

Please do not include organizational brochures or other promotional
materials, slides, films, clips, etc. 

### 4.1.2 Paper Size and Margins {#paper-size-and-margins .unnumbered}

For duplication and scanning purposes, please ensure that the
application can be printed on 8 ½" x 11" white paper. Margins must be at
least one (1) inch at the top, bottom, left and right of the paper.
Please left-align text.

### 4.1.3 Names {#names .unnumbered}

Please include the name of the applicant and 10-digit grant number (if
competing continuation, supplemental or noncompeting continuation) on
each page.

### 4.1.4 Section Headings {#section-headings .unnumbered}

Please put all section headings flush left in bold type.

### 4.1.5 Page Numbering {#page-numbering .unnumbered}

**Electronic Submissions**

For electronic submissions, applicants only have to number the
electronic attachment pages sequentially, resetting the numbering for
each attachment, i.e., start at page 1 for each attachment.

Do not number the standard OMB approved form pages.

**Paper Submissions (When allowed)**

Do not number the standard OMB approved forms. Please number each
attachment page sequentially. Reset the numbering for each attachment.
(Treat each attachment/document as a separate section.)

### 4.1.6 Allowable Attachment or Document Types {#allowable-attachment-or-document-types .unnumbered}

**Electronic Submissions**

The following attachment types are supported in HRSA EHBs. Even though
grants.gov may allow you to upload any type of attachment, it is
important to note that HRSA only accepts the following types of
attachments:

.DOC - Microsoft Word

.RTF - Rich Text Format

.TXT - Text

.WPD - Word Perfect Document

.PDF - Adobe Portable Document Format

.XLS - Microsoft Excel

## 4.2 Application Content Order (Table of Contents) {#application-content-order-table-of-contents .unnumbered}

When applications were submitted in paper, it was easy to direct the
applicants to prepare a table of contents and make it as a part of the
application. Applicants did not have any problem in preparing the
package that included standard forms as well as attachments. All the
pages were numbered sequentially. Preparation instructions were given in
the program guidance. With the transition to electronic application
receipt, this process has changed significantly. HRSA is using an
approach that will ensure that regardless of the mode of submission
(electronic or paper when exemptions are granted), all applications will
look the same when printed for objective review.

HRSA uses two standard packages from Grants.gov.

SF 424 (otherwise known as 5161) -- For service delivery programs

SF 424 R&R -- For research and training programs (programs previously
using the 398 or the 6025 and 2590 application packages)

For each package HRSA has defined a standard order of forms and that
order is available within the program guidance. The program guidance may
also provide applicants with explicit instructions on where to upload
specific documents.

If you are applying on paper (when allowed), you must use the program
guidance for the order of the forms and all other applicable guidelines.

## 4.3 Page Limit {#page-limit .unnumbered}

HRSA prints your application for review regardless of whether it is
submitted electronically or by paper (when allowed).

When your application is printed, the narrative documents may not exceed
80 pages in length unless otherwise stated in the program guidance.
These narrative documents include the abstract, project and budget
narratives, and any other attachments such as appendices, letters of
support required as a part of the guidance. This 80 page limit does not
include the OMB approved forms. Note that some program guidances may
require submission of OMB approved program specific forms as
attachments. These attachments will not be included in the 80 page
limit.

Applicants must follow the instructions provided in this section and
ensure that they print out all attachments on paper and count the number
of pages before submission.

-   Applications, whether submitted electronically or on paper, that
    exceed the specified limits will be deemed non-compliant.
    Non-compliant competing applications will not be given any
    consideration and the particular applicants will be notified.
    Non-compliant noncompeting applications will have to be resubmitted
    to comply with the page limits.

# 5. Customer Support Information

### 5.1.1 Grants.gov Customer Support {#grants.gov-customer-support .unnumbered}

Please direct ALL questions regarding Grants.gov to Grants.gov Contact
Center at Tel.: 1-800-518-4726. Contact Center hours of operation are
Monday-Friday from 7:00 a.m. to 9:00 p.m. Eastern Time, excluding
Federal holidays.

Please visit the following support URL for additional material on
Grants.gov website.

<http://www.grants.gov/CustomerSupport>

### 5.1.2 HRSA Call Center {#hrsa-call-center .unnumbered}

For assistance with or using HRSA EHBs, call 877-GO4-HRSA (877-464-4772)
between 9:00 am to 5:30 pm ET or email <callcenter@hrsa.gov>.

Please visit HRSA EHBs for online help. Go to:

<https://grants.hrsa.gov/webexternal/home.asp> and click on 'Help'

### 5.1.3 HRSA Program Support {#hrsa-program-support .unnumbered}

For assistance with program guidance related questions, please contact
the program contact listed on the program guidance. Do not call the
program contact for technical questions related to either Grants.gov or
HRSA EHBs.

# 6. FAQs

## 6.1 Software {#software .unnumbered}

### 6.1.1 What are the software requirements for using Grants.gov? {#what-are-the-software-requirements-for-using-grants.gov .unnumbered}

Applicants will need to download the PureEdge viewer. Grants.gov website
provides the following information:

**System Requirements:**

For PureEdge Viewer to function properly, your computer must meet the
following system requirements:

Windows 98, ME, NT 4.0, 2000, XP\
500 Mhz processor\
128 MB of RAM\
40 MB disk space\
Web browser: Internet Explorer 5.01 or higher, Netscape Communicator
4.5 - 4.8, Netscape 6.1, 6.2, or 7

If you do not have a Windows operating system, you will need to use a
Windows Emulation program.

Please visit <http://www.grants.gov/DownloadViewer> for all details and
any updates.

### 6.1.2 Why can't I download PureEdge Viewer onto my machine? {#why-cant-i-download-pureedge-viewer-onto-my-machine .unnumbered}

Depending on your organization's computer network and security protocols
you may not have the necessary permissions to download software onto
your workstation. Contact your IT department or system administrator to
download the software for you or give you access to this function.

### 6.1.3 I have heard that Grants.gov is not Macintosh compatible. What do I do if I use only a Macintosh? {#i-have-heard-that-grants.gov-is-not-macintosh-compatible.-what-do-i-do-if-i-use-only-a-macintosh .unnumbered}

Grants.gov is aware of the issues facing Macintosh users who apply for
Federal grants electronically. Grants.gov has provided the following
response regarding this issue on its website at
<http://www.grants.gov/MacSupport>:

> *Grants.gov recognizes that support to users of Non-Windows operating
> systems and the PureEdge Viewer is often required across a distinct
> segment of the grant applicant community. Although at this time, the
> PureEdge Viewer is only available for Windows based installs,
> Grants.gov offers support for Non-Windows platforms.*
>
> *Grants.gov is working with PureEdge in the development of a
> Non-Windows compatible viewer. PureEdge has committed to providing a
> platform independent viewer by November 2006. Information related to
> the Non-Windows compatible viewer will be posted to this webpage
> (http://www.grants.gov/MacSupport). Please bookmark this page and
> return at your convenience for more details.*

Grants.gov and NIH have partnered to provide free access to Citrix
servers for Macintosh Users who are looking for an alternative to using
PC emulation software with the PureEdge forms. A Citrix server
connection allows Macintosh users to remotely launch a Windows session
on their own machines by using the free Citrix client application.
Applicants will need to download and install the free Citrix client
application in order to work. This service is now available for use.

Grants.gov website states:

> *Beginning December 20, 2005, non-Windows users will be able to
> download and complete the PureEdge forms by taking advantage of the
> free Citrix server. Non-Windows users are also able to submit
> completed grant applications via the Citrix environment.*

For details, please visit <http://www.grants.gov/MacSupport>

### 6.1.4 What are the software requirements for HRSA EHBs? {#what-are-the-software-requirements-for-hrsa-ehbs .unnumbered}

HRSA EHBs can be accessed over the Internet using Internet Explorer (IE)
v5.0 and above and Netscape 4.72 and above. HRSA EHBs are 508 compliant.

IE 6.0 and above is the recommended browser.

HRSA EHBs use pop-up screens to allow users to view or work on multiple
screens. Ensure that your browser settings allow for pop-ups.

In addition, to view attachments such as Word and PDF, you will need
appropriate viewers.

### 6.1.5 What are the system requirements for using HRSA EHBs on a Macintosh computer?  {#what-are-the-system-requirements-for-using-hrsa-ehbs-on-a-macintosh-computer .unnumbered}

Mac users are requested to download the latest version of Netscape for
their OS version. It is recommended that Safari v1.2.4 and above or
Netscape v7.2 and above be used.

Note that Internet Explorer (IE) for Mac has known issues with SSL and
Microsoft is no longer supporting IE for Mac. HRSA EHBs do not work on
IE for Mac.

In addition, to view attachments such as Word and PDF, you will need
appropriate viewers.

## 6.2 Application Receipt {#application-receipt .unnumbered}

### 6.2.1 What will be the receipt date\--the date the application is stamped as received by Grants.gov or the date the data is received by HRSA? {#what-will-be-the-receipt-date--the-date-the-application-is-stamped-as-received-by-grants.gov-or-the-date-the-data-is-received-by-hrsa .unnumbered}

**Competing Submissions:**

The submission/receipt date will be the date the application is received
by Grants.gov.

**Noncompeting Submissions:**

The submission/receipt date will be the date the application is
submitted in HRSA EHBs.

### 6.2.2 When do I need to submit my application? {#when-do-i-need-to-submit-my-application .unnumbered}

**Competing Submissions:**

Applications must be submitted to Grants.gov by 8 PM ET on the due date.

**Noncompeting Submissions:**

Applications must be submitted to Grants.gov by 8 PM ET on the due date.

Applications must be verified and submitted in HRSA EHBs by 5:00 PM ET
on the due date. (2 weeks after the due date in Grants.gov) Refer to the
program guidance for specific dates.

### 6.2.3 What emails can I expect once I submit my application? Is email reliable? {#what-emails-can-i-expect-once-i-submit-my-application-is-email-reliable .unnumbered}

**Competing Submissions:**

When you submit your noncompeting application in Grants.gov, it is first
received and validated by Grants.gov. Typically, this takes a few hours
but it may take up to 48 hours during peak volumes. You should receive
two emails from Grants.gov.

The first will confirm receipt of your application by the Grants.gov
system ("Received"), and the second will indicate that the application
has either been successfully validated ("Validated") by the system prior
to transmission to the grantor agency or has been rejected due to errors
("Rejected with Errors").

Subsequently, the application will be downloaded by HRSA. This happens
within minutes of when your application is successfully validated by
Grants.gov and made available for HRSA to download. On successful
download at HRSA, the status of the application will change to "Received
by Agency" and you will receive another email from Grants.gov.

Because email is not reliable, you must check the respective systems if
you do not receive any emails within the specified timeframes.

**Noncompeting Submissions:**

When you submit your noncompeting application in Grants.gov, it is first
received and validated by Grants.gov. Typically, this takes a few hours
but it may take up to 48 hours during peak volumes. You should receive
two emails from Grants.gov.

Subsequently, the application will be downloaded by HRSA. This happens
within minutes of when your application is successfully validated by
Grants.gov and made available for HRSA to download. On successful
download at HRSA, the status of the application will change to "Received
by Agency" and you will receive another email from Grants.gov.

Subsequently, it is processed by HRSA to ensure that the application is
submitted for the correct funding announcement, with the correct grant
number and grantee organization. This may take up to 3 business days. At
this point you will receive an email from HRSA confirming the successful
receipt of your application and asking the PD and AO to review and
resubmit the application in HRSA EHBs.

Because email is not reliable, you must check the respective systems if
you do not receive any emails within the specified timeframes.

-   For more information refer to sections 2.4 and 2.5 in this guide

### 6.2.4 If a resubmission is required because of Grants.gov system problems, will these be considered \"late\"? {#if-a-resubmission-is-required-because-of-grants.gov-system-problems-will-these-be-considered-late .unnumbered}

**Competing Submissions:**

No. But you must **contact the Director of the Division of Grants
Policy** via email at <DGPWaivers@hrsa.gov> and thoroughly explain the
situation. Include a copy of the "Rejected with Errors" notification you
received from Grants.gov.

**Noncompeting Submissions:**

No. But you must **contact the HRSA Call Center** at 877-GO4-HRSA
(877-464-4772) between 9:00 am to 5:30 pm ET or email
<callcenter@hrsa.gov>. You may be asked to provide a copy of the
"Rejected with Errors" notification you received from Grants.gov.

## 6.3 Application Submission {#application-submission .unnumbered}

### 6.3.1 How can I make sure that my electronic application is presented in the right order for objective review? {#how-can-i-make-sure-that-my-electronic-application-is-presented-in-the-right-order-for-objective-review .unnumbered}

Follow the instructions provided in section 4.2 to ensure that your
application is presented in the right order and is compliant with all
the requirements.

## 6.4 Grants.gov {#grants.gov .unnumbered}

For a list of frequently asked questions and answers maintained by
Grants.gov please visit the following URL:

<http://www.grants.gov/GrantsGov_UST_Grantee/!SSL!/WebHelp/GrantsGov_UST_Grantee.htm#index.html>

# Appendix B -- Registering and Applying Through Grants.gov

**Prepare to Apply through Grants.gov:**

HRSA, in providing the grant community a single site to Find and Apply
for grant funding opportunities, is [requiring]{.underline} applicants
for this funding opportunity to apply electronically through Grants.gov.
By using Grants.gov you will be able to download a copy of the
application package, complete it off-line, and then upload and submit
the application via the Grants.gov site. You may [not]{.underline}
e-mail an electronic copy of a grant application to us.

Please understand that we will not consider additional information
and/or materials submitted after your initial application. You must
therefore ensure that all materials are submitted together.

Note: Except in rare cases, paper applications will NOT be accepted for
this grant opportunity. If you believe you are technologically unable to
submit an on-line application you MUST contact the Director of the
Division of Grants Policy, at <DGPWaivers@hrsa.gov> and explain why you
are technologically unable to submit on-line. Make sure you specify the
announcement number you are requesting relief for. HRSA and its Grants
Application Center (GAC) will only accept paper applications from
applicants that received prior written approval.

In order to apply through Grants.gov the Applicant must register with
Grants.gov. This is a three step process that must be completed by any
organization wishing to apply for a grant opportunity. The registration
process will require some time. Therefore, applicants or those
considering applying at some point in the future should register
**[immediately]{.underline}**. Registration in Grants.gov does not
require the organization to apply for a grant; it simply provides the
organization the required credentials so that the organization may apply
for a grant in the future. Registration is required only once.

**[REGISTRATION:]{.underline}**

GET STARTED NOW AND COMPLETE THE ONE-TIME REGISTRATION PROCESS TO BEGIN
SUBMITTING GRANT APPLICATIONS AS SOON AS YOU READ THIS.

You don't need to be registered to search or to begin selecting,
downloading and completing grant applications. Registration is required
to submit applications. Therefore, it is essential that your
organization be registered prior to attempting to submit a grant
application or your organization will not be able to do so. **Be sure to
complete the process early as the registration process may take some
time (anywhere from 5 days to 1 month).**

**There are three steps to the registration process:**

Step 1: Register your organization

Step 2: Register yourself as an Authorized Organization Representative

Step 3: Get authorized by your organization to submit grants

These instructions will walk you through the three basic registration
steps. Additional assistance is available at Grants.gov at
[www.grants.gov](../www.grants.gov). Individual assistance is available
at [http://www.grants.gov/Support](http://www.grants.gov/Support  ) or
1-800-518-4726. Grants.gov also provides a variety of support options
through online Help including Context-Sensitive Help, Online Tutorials,
FAQs, Training Demonstration, User Guide, and Quick Reference Guides.

Follow this checklist to complete your registration---

1\. Register Your Organization

\- Obtain your organization's Data Universal Number System (DUNS) number

\- Register your organization with Central Contractor Registry (CCR)

\- Identify your organization's E-Business POC (Point of Contact)

\- Confirm your organization's CCR "Marketing Partner ID Number (M-PIN)"
password

2\. Register Yourself as an Authorized Organization Representative (AOR)

\- Obtain your username and password

\- Register your username and password with Grants.gov

3\. Get Yourself Authorized as an AOR

\- Contact your E-Business POC to ensure your AOR status

\- Log in to Grants.gov to check your AOR status

The Grants.gov/Apply feature includes a simple, unified application
process to enable applicants to apply for grants online. The information
applicants need to understand and execute the steps is at
http://www.grants.gov/GetStarted. Applicants should read the Get Started
steps carefully. The site also contains registration checklists to help
you walk through the process. HRSA recommends that you download the
checklists and prepare the information requested before beginning the
registration process. Reviewing information required and assembling it
before beginning the registration process will save you time and make
the process faster and smoother.

**REGISTER YOUR ORGANIZATION**

Before you can apply for a grant via Grants.gov, your organization must
obtain a Data Universal Number System (DUNS) number and register early
with the Central Contractor Registry (CCR).

**Obtain your organization's DUNS number**

A DUNS number is a unique number that identifies an organization. It has
been adopted by the Federal government to help track how Federal grant
money is distributed. Ask your grant administrator or chief financial
officer to provide your organization's DUNS number.

\-**How do you do it**? If your organization does not have a DUNS
number, call the special Dun & Bradstreet hotline at 1-866-705-5711 to
receive one free of charge.

\- **How long will this take?** You will receive a DUNS number at the
conclusion of the phone call.

**Register your organization with CCR**

The CCR is the central government repository for organizations working
with the Federal government. Check to see if your organization is
already registered at the CCR website. If your organization is not
already registered, identify the primary contact who should register
your organization.

When your organization registers with CCR, it will be required to
designate an E-Business Point of Contact (E-Business POC). The designee
authorizes individuals to submit grant applications on behalf of the
organization and creates a special password called a Marketing Partner
ID Number (M-PIN) to verify individuals authorized to submit grant
applications for the organization.

\-**How do you do it?** Visit the CCR website at http://www.ccr.gov.
Check whether your organization is already registered or register your
organization right online. Be certain to enter an MPIN number during
this process as this is an optional field for the CCR registration but
mandatory for Grants.gov.

\- **How long will this take?** It may take a few days for you to
collect the information needed for your organization's registration, but
once you finish the registration process, you can move on to Step 2 the
very next business day. Note it will take up to a month for the total
registration- therefore this should be done as soon as possible.

**GET AUTHORIZED as an AOR by Your Organization**

The registration process is almost complete. All that remains is the
final step ---getting authorized. Even though you have registered, your
E-Business POC must authorize you so Grants.gov will know that you are
verified to submit applications.

\- **Obtain your E-Business POC authorization**

After your Authorized Organizational Representative (AOR) profile is
completed, your organization's E-Business POC will receive an email
regarding your requested AOR registration, with links and instructions
to authorize you as an AOR.

\- **How do you do it?** Instruct your E-Business POC to login to
Grants.gov at http://www.grants.gov/ForEbiz and enter your
organization's DUNS number and M-PIN. They will select you as an AOR
they wish to authorize and you will be verified to submit grant
applications.

\- **How long will this take?** It depends on how long it takes your
E-Business POC to log in and authorize your AOR status. You can check
your AOR status by logging in to Grants.gov at
http://www.grants.gov/ForApplicants.

**REGISTER YOURSELF as an Authorized Organization Representative (AOR)**

Once the CCR Registration is complete, your organization is finished
registering. You must now register yourself with Grants.gov and
establish yourself as an AOR, an individual authorized to submit grant
applications on behalf of your organization. There are two elements
required to complete this step --- both must be completed to move onto
Step 3.

1\. **Obtain your username and password**

In order to safeguard the security of your electronic information, and
to submit a Federal grant application via Grants.gov, you must first
obtain a username and password from the Grants.gov Credential Provider.

\- **How do you do it**? Just register with Grants.gov's Credential
Provider at http://www.grants.gov/Register1. You will need to enter your
organization's DUNS number to access the registration form. Once you
complete the registration form you will be given your username and you
will create your own password.

\- **How long will this take?** Same day. When you submit your
information you will receive your username and be able to create your
password.

**2. Register with Grants.gov**

Now that you have your username and password, allow about 30 minutes for
your data to transfer from the Credential Provider, then you must
register with Grants.gov to set up a short profile.

\> **How do you do it?** Simply visit http://www.grants.gov/Register2 to
register your username and password and set up your profile. Remember,
you will only be authorized for the DUNS number which you register in
your Grants.gov profile.

\> **How long will this take?** Same day. Your AOR profile will be
complete after you finish filling in the profile information and save
the information at Grants.gov.

You have now completed the registration process for Grants.gov. If you
are applying for a [new or competing continuation]{.underline} you may
find the application package through Grants.gov FIND. If you are filling
out a [non-competing continuation]{.underline} application you must
obtain the announcement number through your program office, and enter
this announcement number in the search field to pull up the application
form and related program guidance. Download the required forms and enter
your current grant number in the

appropriate field to begin the non-competing continuation application
which you will then upload for electronic submittal through Grants.gov.
For continuation applications which require submittal of performance
measures electronically, instructions are provided in the program
guidance on how to enter the HRSA electronic handbooks to provide this
information.

**How to submit an electronic application to HRSA via Grants.gov/Apply**

a\. [Applying using Grants.gov.]{.underline} Grants.gov has a full set
of instructions on how to apply for funds on its website at
<http://www.grants.gov/CompleteApplication>. The following provides
simple guidance on what you will find on the Grants.gov/Apply site.
Applicants are encouraged to read through the page entitled, "Complete
Application Package" before getting started. See Appendix A for specific
information.

b\. [Customer Support]{.underline}. The grants.gov website provides
customer support via (800) 518-GRANTS (this is a toll-free number) or
through e-mail at support@grants.gov. The customer support center is
open from 7:00 a.m. to 9:00 p.m. Eastern time, Monday through Friday,
except federal holidays, to address grants.gov technology issues. For
technical assistance to program related questions, contact the number
listed in the Program Section of the program you are applying for.

**Timely Receipt Requirements and Proof of Timely Submission**

a\. Electronic Submission. All applications must be received by
www.grants.gov/Apply by 8:00 P.M. Eastern Time on the due date
established for each program.

Proof of timely submission is automatically recorded by Grants.gov. An
electronic time stamp is generated within the system when the
application is successfully received by Grants.gov. The applicant will
receive an acknowledgement of receipt and a tracking number from
Grants.gov with the successful transmission of their application.
Applicants should print this receipt and save it, along with facsimile
receipts for information provided by facsimile, as proof of timely
submission. When HRSA successfully retrieves the application from
Grants.gov, Grants.gov will provide an electronic acknowledgment of
receipt to the e-mail address of the AOR. Proof of timely submission
shall be the date and time that Grants.gov receives your application.

Applications received by grants.gov, after the established due date and
time for the program, will be considered late and will not be considered
for funding by HRSA. HRSA suggests that applicants submit their
applications during the operating hours of the Grants.gov Support Desk,
so that if there are questions concerning transmission, operators will
be available to walk you through the process. Submitting your
application during the Support Desk hours will also ensure that you have
sufficient time for the application to complete its transmission prior
to the application deadline. Applicants using dial-up connections should
be aware that transmission should take some time before Grants.gov
receives it. Grants.gov will provide either an error or a successfully
received transmission message. The Grants.gov Support desk reports that
some applicants abort the transmission because they think that nothing
is occurring during the transmission process. Please be patient and give
the system time to process the application. Uploading and transmitting
many files, particularly electronic forms with associated XML schemas,
will take some time to be processed.

Note the following additional information regarding submission of all
HRSA applications through Grants.gov:

• You must submit all documents electronically, including all
information typically included on the SF424 and all necessary assurances
and certifications.

• Your application must comply with any page limitation requirements
described in this program announcement.

• After you electronically submit your application, you will receive an
automatic acknowledgement from Grants.gov that contains a Grants.gov
tracking number. HRSA will retrieve your application from Grants.gov.

Online applications are required to submit ONLY one form in signed hard
copy: the SF-424/5161 Face Sheet, since all other elements of the
application have been captured and transmitted electronically. This face
page should be sent to HRSA's Grants Application Center at:

The HRSA Grants Application Center

The Legin Group, Inc.

Attn: \[provide Grants.gov Tracking Number\]

> Program Announcement No. \[provide HRSA announcement number\]
>
> CFDA No. \[provide the CFDA number\]

910 Clopper Road, Suite 155 South

Gaithersburg, MD 20878

Telephone: 877-477-2123

**Formal Submission of the Electronic Application**

Applications completed online are considered formally submitted when the
Authorizing Official electronically submits the application to HRSA
through Grants.gov. However, to complete the submission requirements, a
hard-copy of the SF-424/5161 Face Sheet must be printed, signed, and
submitted to the HRSA Grants Application Center. For competitive
applications, the SF-424/5161 must be printed from Grants.gov.

For an online application, the signed SF-424/5161 must be sent to the
HRSA GRANTS APPLICATION CENTER at the above address and received by HRSA
by no later than five days after the date of submission in Grants.gov.

Competitive applications will be considered as having met the deadline
if: (1) the application has been successfully transmitted electronically
by your organization's Authorizing Official through Grants.gov on or
before the deadline date and time, and (2) the signed SF-424/5161 Face
Sheet is received by HRSA no later than five days after submission in
Grants.gov.

**Performance Measures for Competitive Applications**

Many HRSA guidances include specific data forms and require performance
measure reporting. If the completion of performance measure information
is indicated in this guidance, successful applicants receiving grant
funds will be required, within 30 days of the Notice of Grant Award
(NGA), to register in HRSA's Electronic Handbooks (EHBs) and
electronically complete the program specific data forms that appear in
this guidance. This requires the provision of budget breakdowns in the
financial forms based on the grant award amount, the project abstract
and other grant summary data, and objectives for the performance
measures.

**Performance Measures for Non-Competing Continuation Applications**

For applications which require submittal of performance measures
electronically through the completion of program specific data forms,
instructions will be provided both in the program guidance and through
an e-mail, notifying grantees of their responsibility to provide this
information, and providing instructions on how to do so.

# 

# 

# 

# 

# 

# APPENDIX C:

# PROGRAM SPECIFIC FORMS WITH INSTRUCTIONS 

**Program Specific Forms Instructions**

Bureau of Primary Health Care (BPHC) program-specific forms #1- 9 should
be uploaded under Attachment #2 under Attachments Form in Grants.gov.
All forms should be merged into one document. Please note that only the
OMB forms, approved by the U.S. Office of Management and Budget, should
be submitted with the SAC-Additional Areas application (included in this
Appendix).

-   Forms 1 -- 5, 6 -- Part A, and 9 are required for all applicants.

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```
-   Form 1 PART B: BPHC Funding Request Summary is **NO LONGER**
    required for SAC-Additional Areas applicants.

-   Form 7: Compliance Checklist is **NO LONGER** required for
    SAC-Additional Areas applicants.

-   Only applicants requesting a waiver for governance requirements must
    submit Form 6 -- Part B.[^12] **Please Note:** Applicants currently
    receiving section 330 funding and applying to serve their current
    service area must also reapply for approval as part of their
    SAC-Additional Areas application by completing and submitting Form
    6-B to continue their existing governance waiver for a new project
    period.

-   Only CHC and/or MHC applicants must submit Form 8 -- Part A and only
    those CHC and/or MHC applicants with proposed affiliation
    arrangements must submit Form 8 -- Part B.

######## **FORM 1, Part A -- General Information Worksheet (Required)**

> Form 1 -- Part A: General Information Worksheet provides a summary of
> information related to the proposed budget, Health Care and Business
> Plans, patient and encounter projections presented in the project
> description and other forms. The following instructions are intended
> to clarify the information to be reported in each section of the form.
>
> The applicant should complete Form 1- Part A based on the proposed
> project at the time of application submission. Applicants currently
> receiving section 330 funding and applying to serve their current
> service area **cannot** request a change in their approved scope of
> project (e.g. adding or deleting sites or services) in the
> SAC-Additional Areas application and data reported in this form should
> not reflect pending changes in scope that have not yet been approved
> by the HRSA project officer.[^13]

[DESCRIPTION OF PROPOSED SERVICE AREA:]{.underline}

1.  List all of the cities, counties, zip codes and census tracts served
    by the applicant under the proposed project. If the list does not
    fit in the space provided, attach a list organized by service site
    in Attachment 13: Other Relevant Documents.

2.  Do not include cities, counties, zip codes and/or census tracts
    representing patients that may receive services from the applicant
    but are outside the applicant's service area. Please refer to the
    definition of service area found in Appendix H: Service Area
    Competition Definitions.

> [ORGANIZATION TYPE:]{.underline}
>
> SAC-Additional Areas applicants may be considered either a private
> non-profit or a public entity. Please select the organization type (s)
> which best describes your organization.
>
> [SERVICE AREA TYPE:]{.underline}

-   Select the designation(s) and or descriptors (urban, rural, and/or
    sparsely populated) which best describe the applicant's proposed
    service area. Sparsely populated areas are geographical areas with 7
    people or less per square mile for the entire service area. Multiple
    selections are allowed.

-   For inquiries regarding Medically Underserved Areas of Medically
    Underserved Populations, call 1-888-275-4772. Press option 1, then
    option 2 or contact the Shortage Designation Branch via email
    <sdb@hrsa.gov> or 301-594-0816. For additional information, visit
    the HRSA Bureau of Health Professions Shortage Designation website
    at <http://bhpr.hrsa.gov/shortage/>.

> [POPULATIONS:**\
> **]{.underline}For this section, applicants with more than one
> delivery site should report aggregate data for all of the sites
> included in the proposed project.
>
> Form 1 -- Part A requests both current and proposed information.
> "Current" refers to the number of patients and/or encounters served by
> the applicant at the time of application. "Proposed" refers to the
> number of patients and/or encounters anticipated to be served by the
> applicant by the end of the project period (up to 5 years) at the
> current level of level of funding.
>
> *Table A: Patients and Encounters by Type of Service*

1.  An applicant currently receiving section 330 funding and applying to
    serve its current service area should list current patients and
    encounters based on the most recent submission to the Uniform Data
    System. An applicant who is not receiving section 330 funding to
    serve an area listed in Appendix F should list the current number of
    patients and encounters as zero and include the number of proposed
    patients and encounters in the appropriate columns.

2.  In the event an applicant currently receiving section 330 funding
    and applying to serve its current service area has received a New
    Access Point, Expanded Medical Capacity, and/or Service Expansion
    award in the previous budget period, the applicant should include
    the projected increase in the number of patients and encounters in
    the "proposed" column consistent with the approved application.

3.  Applicants are expected to sustain and/or increase patients and/or
    encounters through the period at the current level of funding.
    **Therefore, HRSA does not expect the number of patients and/or
    encounters to decline over the project period**.

4.  Do not report patients and encounters for services outside the
    organization's proposed project.

> *Table B: Patients and Encounters by Funding Type*

1.  An applicant currently receiving section 330 funding and applying to
    serve its current service area should list current patients and
    encounters based on the most recent submission to the Uniform Data
    System. An applicant who is not receiving section 330 funding to
    serve an area listed in Appendix F should list the current number of
    patients and encounters as zero and include the number of proposed
    patients and encounters in the appropriate columns.

2.  In the event an applicant currently receiving section 330 funding
    and applying to serve its current service area has received a New
    Access Point, Expanded Medical Capacity, and/or Service Expansion
    award in the previous budget period, the applicant should include
    the projected increase in the number of patients and encounters in
    the "proposed" column consistent with the approved application.

3.  Applicants are expected to sustain and/or increase patients and/or
    encounters through the period at the current level of funding.
    **Therefore, HRSA does not expect the number of patients and/or
    encounters to decline over the project period**.

4.  Do not report patients and encounters for services outside the
    organization's proposed project.

5.  When providing an unduplicated count of patients and encounters
    please note the following guidelines:

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```
a.  Encounters are defined to include a documented, face-to-face contact
    between a patient and a provider who exercises independent judgment
    in the provision of services to the individual. To be included as an
    encounter, services rendered must be documented.

b.  Since patients must have at least one documented encounter, it is
    not possible for the number of patients to exceed the number of
    encounters. 

> *Table C: Requested Funding and Total Budget*

1.  For an applicant currently receiving section 330 funding and
    applying to serve its current service area, the maximum level of
    support is the amount listed on line 13 or line 19 of your **[most
    recent]{.underline}** Notice of Grant Award (NGA). Please do not
    make additional calculations for anticipated awards, rescissions,
    and/or base adjustments. An applicant who is not receiving section
    330 funding to serve an area listed in Appendix F should submit
    information for up to a 5 year project period. **All funding
    requests should be level over the length of the project period
    (i.e., no increase or decrease between years) and in accordance with
    the current level of targeted support.**

> *Table D: Current Provider FTEs by Type*

1.  An applicant currently receiving section 330 funding and applying to
    serve its current service area should report the number of provider
    FTEs by staff type at the time of application. An applicant who is
    not receiving section 330 funding to serve an area listed in
    Appendix F should list the current number of providers as zero.

2.  An applicant should report the number of proposed provider FTEs by
    staff type.

3.  Applicants are expected to sustain and/or increase the number of
    provider FTEs throughout the project period. **Therefore, HRSA does
    not expect the number of providers to decline over the project
    period.**

    -   **FORM 1, Part B -- BPHC-Funding Request Summary -- No LONGER
        required for SAC-ADditional areas applicants**

    -   **FORM 1, PART C -- Documents ON File (Required)**

> Documents categorized under "Documents on File" must be kept at the
> applicant organization and should be made available to the Project
> Officers **[upon request]{.underline}** within 3-5 business days. **DO
> NOT** include these items as part of the SAC-Additional Areas
> application. Please provide the date that each document was last
> revised in the form.

-   **FORM 2 -- Staffing Profile (First Year Only - Required)**

> The Staffing Profile reports personnel salaries supported by the total
> budget for the [first year]{.underline} of the proposed project.
> Applicants should include staff for the entire scope of the project
> (i.e., total for all sites). Anticipated staff changes within the
> proposed project period should be addressed in the program narrative.

-   **FORM 3 -- Income Analysis Form (First Year Only - Required)**

> Each applicant must complete the Income Analysis Form. The form
> projects program income, by source, for the [first year]{.underline}
> of the proposed project period. Anticipated changes within the
> proposed project period should be addressed in the budget
> presentation.

## [[Instructions For The Completion Of Form 3: Income Analysis]{.underline}]{.smallcaps} 

The Income Analysis Form provides a format for presenting the estimated
non-federal revenues **(all other sources of income ASIDE FROM the
section 330 grant funds)** for the application budget. Any specific
entries that require additional explanation (e.g. projections that
include reimbursement for billable events that the UDS does not count as
encounters) should be discussed in the "Comments/Explanatory Notes" box
at the bottom of page 2 of the form and if necessary, detailed in the
Budget Justification. Applicants should not use this form to provide
additional narrative beyond that included in the Program narrative. The
worksheet must be based on the proposed project. It may not include any
grant funds from any pending supplemental grants or other unapproved
changes in sites, services or capacity.

> There are two major classifications of revenues, Program Income and
> Other Income.

-   **Part 1: Program Income** includes fees, premiums and third party
    reimbursements and payments generated from the projected delivery of
    services. Program income is divided into two types of income: Fee
    for Service and *capitated* Managed Care.

-   **Part 2: Other Income** includes State, Local or other Federal
    grants (e.g. Ryan White, HUD, Head Start) or contracts and local or
    private support that is NOT generated from charges for services
    delivered.

> **If the categories in the worksheet do not describe all possible
> categories of Program or Other Income, such as "pharmacy", applicants
> may add lines for any additional income source [if
> necessary.]{.underline}** Clarifications for these additions may be
> noted in the "Comments/Explanatory Notes" box at the bottom of page 2
> of the form.
>
> **PART 1: PROGRAM INCOME**

**NOTE:** *Not all visits reported on this form are reported on the UDS
report and similarly, not all visits reported on the UDS are included
here. This form reports only on those visits which are billable to first
or third parties including individuals who, after the sliding discount,
may pay little or none of the actual charge.*

# *[PROJECTED FEE FOR SERVICE INCOME]{.underline}* 

> **Lines 1a.-1e. and 2a. -- 2b (Medicaid and Medicare):** Show income
> from Medicaid and Medicare *regardless of whether there is another
> intermediary involved.* For example, if the applicant has a Blue Cross
> fee-for-service managed Medicaid contract, the information would be
> included on lines 1a.-1e., not on lines 3a.-3c. If the State Child
> Health Insurance Program (S-CHIP) is paid through Medicaid, include it
> in the appropriate category on lines 1a-1e. In addition, if the
> applicant receives Medicaid reimbursement via a Primary Care Case
> Management (PCCM) model, this income should be included on line 1e.
> "Medicaid: Other Fee for Service."
>
> **Line 5 (Other Public):** Include here any S-CHIP program NOT paid
> through the Medicaid program as well as any other state or local
> programs that pay for visits including Title X family planning visits,
> CDC's Breast and Cervical Cancer Early Detection Program, Title I and
> II Ryan White visits, etc.

**Column (a):** Enter the number of billable visits that will be covered
by each category and payment source: Medicaid, Medicare, other
third-party payors and uninsured self-pay patients.

**Column (b):** Enter the average charge per visit by payor category. A
sophisticated analysis of charges will generally reveal different
average charges, for example, Medicare charges may be higher than
average Medicaid EPSDT charges. If this level of detail is not
available, averages may be calculated on a more general level (i.e., at
the payor or service type or agency level.)

**Column (c):** Enter Total Gross Charges before any discount or
allowance for each payment category calculated as \[columns (a)\*(b)\].

> **Column (d):** Enter the average adjustment to the average charge per
> visit in column (b). A negative number reduces and a positive number
> increases the Net Charges calculated in column (e). (In actual
> operation, adjustments may be taken either before or after the bill is
> submitted to a first or third party.) Adjustments reported here do NOT
> include adjustments for bad debts. These are shown in column f and g.
> Adjustments in column (d) include those related to:

a)  Projected contractual allowances or discounts to the average charge
    per visit.

b)  Sliding discounts given to self-pay patients.

c)  Adjustments to bring the average charge up/down to the negotiated
    FQHC or Prospective Payment System established reimbursement rate or
    the cost based reimbursement expected after completion of a cost
    reimbursement report.

d)  Any other applicable adjustments. These should be discussed in the
    "Comments/Explanatory Notes" box at the bottom of page 2 of the
    form.

> **Column (e):** Enter the total Net Charges by payment source
> calculated as \[columns c-(a\*d)\]. Net charges are gross charges less
> adjustments described in column d.  
>
> **Column (f):** Based on previous experience, enter the estimated
> collection rate (%) by payor category. The collection rate is the
> amount projected to be collected divided by the amount actually
> billed. As a rule, collection rates will not exceed 100%, and may be
> less than 100% due to factors such as bad debts (especially for self
> pay), billing errors, or denied claims not re-billable to another
> source. Explain any rate greater than 100% using the
> "Comments/Explanatory Notes" section of the form.
>
> **NOTE:** *Do not show sliding discount percentages here -- they are
> included above in column (d); do show the collection rate for actual
> direct patient billings.*
>
> **Column (g):** Enter Projected income for each payor category
> calculated as:
>
> column (e) \* column (f)
>
> **Column (h):** Enter the actual accrued income by payor category for
> the most recent 12- month period for which data are available. Any
> significant variance between projected income (columns g) and actual
> accrued income (column and h) should be explained in the SUPPORT
> REQUESTED review criterion in the Program Narrative portion of the
> application. Applicants who are not receiving section 330 funding to
> serve an area listed in Appendix F should report zero in this column.

## [PROJECTED CAPITATED MANAGED CARE INCOME]{.underline} 

> This section applies only to capitated programs. Visits provided under
> a fee-for-service managed care contract are included in the
> fee-for-service section of this Form. Note also that, unlike the
> fee-for-service section of this Form, applicants will lump together
> all types of services on a single line for the type of payor. Thus,
> capitated Medicaid dental visits and capitated Medicaid medical visits
> are added together and reported on line 7a.
>
> **Number of Member Months (Column a):** "Member months" are the number
> of member months for which the applicant receives payment. One person
> enrolled for one month is one member month; a family of five enrolled
> for six months is 30 member months. A member month may cover just
> medical services or medical and dental or an even more unique mix of
> services. Unusual service mixes which provide for unusually high or
> low PMPM payments should be described in the notes section.
>
> **Rate per Member Month (Column b):** Also referred to as PMPM rate.
> This is the average payment across all managed care contracts for one
> member. PMPM rates may actually be based on multiple age/gender
> specific rates or on service specific plans, but all these should be
> averaged together for a "blended rate" for the provider type.
>
> **Risk Pool Adjustment (Column c):** This is an *estimate* of the
> *total* amount that will be earned from risk or performance pools. It
> includes any payment made by the HMO to the applicant for effectively
> and efficiently managing the health care of the enrolled members. It
> is almost always for a prior period, but must be accounted for in the
> period it is received. Describe risk pools in the narrative. Risk
> pools may be estimated by using the average risk pool receipt PMPM
> over an appropriate prior period selected by the applicant.
>
> **FQHC and Other Adjustments (Column d):** This is the *total* amount
> of payments made to the applicant to cover the difference between the
> PMPM amount paid for Medicaid or Medicare managed care visits and the
> applicant's PPS/FQHC rate.
>
> **Projected Gross Income (Column e):** Column e is calculated for each
> line as:
>
> \[column (a)\* column (b)\] + \[column c + column d\] = e.
>
> **PART 2: OTHER INCOME**

This category includes all non-section 330 income not entered elsewhere
on this table. It includes grants for services, construction, equipment
or other activities that support the project, *where the revenue is not
generated from services provided or visit charges as well as* income
generated from fundraising and contributions, foundations, etc. Line 9.
"Applicant" refers to any income generated by the applicant through the
expenditure of its OWN assets such as income from reserves or realized
sale of property.

Please note that in-kind donations should NOT be included in the Income
Analysis; however applicants may discuss in-kind contributions as
applicable, in the Program Narrative.

-   **FORM 4 -- Community Characteristics (Required)**

> The Community Characteristics form reports service area and target
> population data for the entire scope of the project (i.e., all sites)
> for the most recent period for which data are available. Service area
> data should be specific to the proposed project. Target population
> data should be a subset of the service area data and reflect the
> population the applicant will serve. If information for your service
> area is not available, utilize data from US Census Bureau, local
> planning agencies, health departments and other local, State and
> national data sources. Estimates are acceptable.

-   **FORM 5, Part A -- Services Provided (Required)**

> Applicants must identify what services will be available at the
> site(s) for the entire organization and how these services will be
> provided. Only one form is required for the services provided by the
> entire organization at all sites.

-   **FORM 5, Part B -- Service Sites (Required)**

> The applicant should provide the name and address of each service site
> that meets the definition of a site (see Section Appendix H for a
> definition of service site) in Form 5 -- Part B: Service Sites. An
> applicant currently receiving section 330 funding and applying to
> serve its current service area should include addresses for only those
> service sites that are included under the approved scope of project
> and may **NOT** request support of a new site under this application.
> Any new additions or deletions of sites must be requested through the
> Change in Scope process, consistent with the guidance provided in PIN
> 2002-07. An applicant who is not receiving section 330 funding to
> serve an area listed in Appendix F should list all proposed service
> sites**.**
>
> *[Special Instructions for Recording Mobile Van Sites]{.underline}*
>
> A mobile van that provides primary care services at multiple locations
> is considered a service site. For each mobile van, applicants should
> identify the site as a mobile van and list the address for the
> applicant on Form 5 -- Part B. The specific locations where the van
> provides the services do not need to be listed. However, the general
> area where services are provided (i.e. counties, cities, towns) should
> be listed.
>
> *Special Instructions for Recording Intermittent Service Sites*
>
> Applicants may provide direct health care services at intermittent
> locations that are operated for a limited period of time and change
> locations frequently (e.g., every 1-2 months). Additionally, some
> health centers may also provide services to migrant and seasonal
> farmworkers and their families through contractual voucher
> arrangements. Under these arrangements, services may not be provided
> on a regular scheduled basis but are available during the limited time
> period necessary for that population. Health centers should list these
> intermittent locations as a category (e.g., "Migrant Camps," "Voucher
> Contract Locations") on Form 5 -- Part B: Service Sites. The specific
> service locations under the category where the health center provides
> the services do not need to be listed; however, the number of such
> locations should be indicated on Form 5 -- Part B: Service Sites.
> Applicants should list the number of locations under "# of hours per
> week services are available at the site" instead of the specific hours
> for the locations.

-   **FORM 5, Part C -- Other Activities/Locations (As applicable)**

> Applicants should reference definition of service site in Appendix H
> to determine those activities or locations that should be listed on
> this form. Service sites should be listed on Form 5 - Part B. HRSA
> recognizes that some delivery "activities/locations" have been
> approved as part of the scope of project for applicants currently
> receiving section 330 funding and have therefore appeared on
> previously submitted Form 5 - Part B Service Site Forms. Although not
> considered sites as defined in Appendix H, these
> "activities/locations" should to be documented in continuation
> applications on Form 5 - Part C to be considered part of the approved
> scope of project.
>
> Applicants may provide services at locations that are included in the
> scope of project that do not meet the definition of a service site.
> The category of these locations should be listed on Form 5 -- Part C.
> The specific address of these locations is not required. [Applicants
> should also briefly describe the services provided]{.underline} at
> these locations on Form 5 -- Part C: Other Activities/Locations. Some
> examples of other activities and locations include:

-   Providing immunizations at multiple different day care centers.
    Applicants should list the category "immunizations at day care
    centers."

-   Hospitals, in instances where providers follow the organization's
    patients (rounding/making rounds). Applicants should list the
    category, "hospital."

-   Hospitals, in instances where providers see non-patients as part of
    his/her privileges (on call). Applicants should list the category,
    "hospital."

-   Patients' homes, if it is the policy of the organization that
    providers will occasionally make home visits to an organization's
    patients. Applicants should list "patients' homes."

-   Participating in health fairs. Applicants should list "health
    fairs."

-   Conducting street outreach. Applicants should list "street
    outreach."

-   Providing health education. Applicants should list "health
    education."

```{=html}
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```
-   **FORM 6, Part A -- Board Member Characteristics (Required)**

> All applicants must complete the Board Member Characteristics form.
> Applicants should list all current board members and provide
> information on all characteristics as requested.

-   **FORM 7 -- Compliance Checklist -- No LONGER required for
    SAC-Additional applicants**

```{=html}
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```
-   **FORM 8, Part A - Health Center Affiliation Certification (Required
    for chc and/OR mhc applicants ONLY)**

> Submission of Form 8 -- Part A is required for CHC and/or MHC
> applicants. Applicants should indicate if any of the identified
> affiliation arrangements are present or proposed. Applicants must
> complete a separate Form 8 --Part A for each organization with which
> they have any identified affiliation arrangements. If any of the
> affiliation arrangements are present or proposed, applicants must also
> complete and submit FORM 8 -- Part B.

-   **FORM 8, Part B - Health Center Affiliation Checklist (As
    Applicable)**

> CHC and/or MHC applicants with current or proposed affiliation
> arrangements identified in FORM 8 -- Part A, must also submit a
> completed FORM 8 -- Part B. The completed checklist will provide
> information regarding any current or proposed affiliation
> arrangements. This information will be used to assure that
> organizations receiving section 330 funds comply with the requirements
> and guidelines set forth in PIN 98-23 Health Center Program
> Expectations and PINs 97-27 and 98-24 (available at
> [www.bphc.hrsa.gov/pinspals/pinsarchive.htm](http://www.bphc.hrsa.gov/pinspals/pinsarchive.htm)).
> A summary of all subrecipient arrangements, contracts and affiliations
> agreements should be included in Attachment 8: Summary of Contracts,
> Agreements and Subrecipient Arrangements.

-   **FORM 9 -- Annual Emergency Preparedness and Management (EPM)
    Report (Required)**

> The Annual Emergency and Management Report will be used to assess the
> status of emergency preparedness planning, progress towards developing
> and implementing an emergency management plan and assist in
> determining technical assistance, training and resource needs.

**FORM 1 -- PART A: GENERAL INFORMATION WORKSHEET**

**CONTACT INFORMATION:**

Applicant Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Mailing/Street Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City, State, Zip:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact Person:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Fax:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Email:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**DESCRIPTION OF PROPOSED SERVICE AREA:**

Service Area City, County, State and Relevant Zip Codes:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Service Area Census Tracts:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**ORGANIZATION TYPE (Please Check only ONE):**

\_\_\_\_\_\_ PRIVATE NONPROFIT (Circle the type(s) of organization
below):

Tribal/Urban Indian Faith-based Hospital Other

\_\_\_\_\_\_ PUBLIC CENTER (Circle the type(s) of organization below):

Public Health Department Local Government Public Hospital Public
University Other

**SERVICE AREA TYPE:**

MEDICALLY UNDERSERVED AREA MEDICALLY UNDERSERVED POPULATION N/A

URBAN RURAL SPARSELY POPULATED/FRONTIER (persons/mile\_\_\_\_\_\_\_\_)

**POPULATIONS:**

Total Persons in the Service Area: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Total Persons in the Target Population:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Table A. Patients and Encounters by Type of Service Table B. Patients
and Encounters by Population Type

Table C. Requested Funding and Total Budget

\*\*Including school-aged patients.

Table D: Provider FTEs by Type

######## **FORM 1 -- Part C: DOCUMENTS ON FILE**

Please provide the date that each document was last revised in the table
below.

The following documents must be kept on file at the applicant
organization and should be made available to the Project Officer **[upon
request]{.underline}** within 3-5 business days. **DO NOT** include
these items as part of the SAC-Additional Areas application.

> FORM 2 - STAFFING PROFILE

+-----------------------------------------+--------+--------+--------+
| **PERSONNEL BY CATEGORY**               | *      | **     | *      |
|                                         | *TOTAL | ANNUAL | *TOTAL |
|                                         | FTEs** | SALARY | SA     |
|                                         |        | OF     | LARY** |
|                                         | { a }  | POSI   |        |
|                                         |        | TION** | { a \* |
|                                         |        |        | b }    |
|                                         |        | { b }  |        |
+-----------------------------------------+--------+--------+--------+
| **ADMINISTRATION**                      |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Executive Director / CEO              |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Finance Director (Fiscal Officer) /   |        |        |        |
| > CFO                                   |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Chief Operating Officer/ COO          |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Chief Information Officer/ CIO        |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Administrative Support Staff          |        |        |        |
+-----------------------------------------+--------+--------+--------+
| **MEDICAL STAFF**                       |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Medical/Clinical Director             |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Family Practitioners                  |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > General Practitioners                 |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Internists                            |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > OB/GYNs                               |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Pediatricians                         |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Other Specialty Physicians - Please   |        |        |        |
| > list                                  |        |        |        |
| :\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Physician Assistants/Nurse            |        |        |        |
| > Practitioners,                        |        |        |        |
| >                                       |        |        |        |
| > Certified Nurse Midwives              |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Nurses (RNs, LVNs, LPNs)              |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Pharmacist, Pharmacy Support,         |        |        |        |
| > Technicians                           |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Other Medical Personnel - Please      |        |        |        |
| > list:\_\_\                            |        |        |        |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Laboratory Personnel (Lab             |        |        |        |
| > Technicians)                          |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > X-ray Personnel                       |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Clinical Support Staff (Medical       |        |        |        |
| > Assistants, etc)                      |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Volunteer Clinical Providers (Medical |        | \$0.00 | N/A    |
| > and Dental                            |        |        |        |
+-----------------------------------------+--------+--------+--------+
| **DENTAL STAFF**                        |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Dentists                              |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Dental Hygienists                     |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Dental Assistants, Aides, Technicians |        |        |        |
+-----------------------------------------+--------+--------+--------+
| **MENTAL HEALTH STAFF**                 |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Mental Health Specialists (MH         |        |        |        |
| > Provider)                             |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Alcohol and Substance Abuse           |        |        |        |
| > Specialists                           |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Psychiatrists                         |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Psychologists                         |        |        |        |
+-----------------------------------------+--------+--------+--------+
| **ENABLING STAFF**                      |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Patient Education Specialist (Health  |        |        |        |
| > Educator)                             |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Case Managers                         |        |        |        |
+-----------------------------------------+--------+--------+--------+
| > Outreach (Outreach Staff)             |        |        |        |
+-----------------------------------------+--------+--------+--------+
| Other Enabling                          |        |        |        |
+-----------------------------------------+--------+--------+--------+
| **OTHER PROFESSIONAL STAFF**            |        |        |        |
+-----------------------------------------+--------+--------+--------+
| **OTHER STAFF**                         |        |        |        |
+-----------------------------------------+--------+--------+--------+

<table>
<colgroup>
<col style="width: 24%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 15%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14"><strong>Part 1: Non-Federal Share, Program
Income</strong></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Payor Category</strong></td>
<td><strong>Number of Visits</strong></td>
<td colspan="2"><strong>Average Charge Per Visit</strong></td>
<td><p><strong>Gross CHARGES</strong></p>
<p><strong>(a * b)=(c)</strong></p></td>
<td colspan="2"><strong>Average Adjustment Per Visit</strong></td>
<td><p><strong>Net Charges</strong></p>
<p><strong>(Amount Billed)</strong></p>
<p><strong>[c-(a*d)]</strong></p></td>
<td colspan="2"><p><strong>Collection Rate</strong></p>
<p><strong>(%)</strong></p></td>
<td><p><strong>Projected Income</strong></p>
<p><strong>(e * f)</strong></p></td>
<td colspan="2"><strong>Actual Accrued Income Past 12
Months</strong></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td><strong>(a)</strong></td>
<td colspan="2"><strong>(b)</strong></td>
<td><strong>(c)</strong></td>
<td colspan="2"><strong>(d)</strong></td>
<td><strong>(e)</strong></td>
<td colspan="2"><strong>(f)</strong></td>
<td><strong>(g)</strong></td>
<td colspan="2"><strong>(h)</strong></td>
</tr>
<tr class="even">
<td colspan="14"><strong>PROJECTED FEE FOR SERVICE INCOME</strong></td>
</tr>
<tr class="odd">
<td colspan="2">1a. Medicaid: Medical</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">1b. Medicaid: EPSDT (if different from medical
rate)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">1c. Medicaid: Dental</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">1d. Medicaid: MH/SA</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">1e. Medicaid: Other Fee for Service</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2"><strong>1. Subtotal: Medicaid</strong></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">2a. Medicare: all inclusive FQHC rate</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">2b. Medicare: other Fee for Service</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>2. Subtotal: Medicare</strong></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">3a. Private Insurance (Medical)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">3b. Private Insurance (Dental)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">3c. Private Insurance (MH/SA)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>3. Subtotal: Private</strong></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">4a. Self-Pay: 100% charge, no discount (Medical)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">4b. Self-Pay: 0% – 99% of charge, Sliding discounts
including full discount (Medical)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">4c. Self-Pay: 100% charge, no discount (Dental)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">4d. Self-Pay: 0% - 99% of charge, Sliding discounts
including full discount (Dental)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">4e. Self-Pay: 100% charge, no discount (MH/SA)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">4f. Self-Pay: 0% - 99% of charge, sliding discount
including full discount, (MH/SA)</td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2"><strong>4. Subtotal: Self-Pay</strong></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>5. Subtotal: Other Public</strong></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2"><strong>6. Total Fee For Service</strong></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="14"><h4
id="projected-capitated-managed-care-income-1">PROJECTED CAPITATED
MANAGED CARE INCOME</h4></td>
</tr>
<tr class="even">
<td><strong>TYPE OF PAYOR</strong></td>
<td colspan="3"><p>Number of Member Months</p>
<p>(a)</p></td>
<td colspan="3"><p>Rate Per Member Month</p>
<p>(b)</p></td>
<td colspan="3"><p>Risk Pool Adjustment</p>
<p>(c)</p></td>
<td colspan="3"><p>FQHC and Other Adjustments</p>
<p>(d)</p></td>
<td><p>Projected Gross Income</p>
<p>(e)</p></td>
</tr>
<tr class="odd">
<td>7a. Medicaid:</td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td>7b. Medicare</td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td>7c. Commercial</td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td>7d. Other Public</td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>7. Total Capitated Managed Care</strong></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td><strong>8. Managed Care Charges</strong></td>
<td colspan="5">(a) Visits</td>
<td colspan="5">(b) Average Charge Per Visit</td>
<td colspan="3">(c) Total Charges</td>
</tr>
<tr class="odd">
<td><h3 id="section-5"></h3></td>
<td colspan="5"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="6"><strong>TOTAL PROGRAM INCOME [line 6, column g + line 7,
column e] Matches line 7 “Program Income “of SF 424A</strong></td>
<td colspan="8"></td>
</tr>
</tbody>
</table>

**FORM 3 - INCOME ANALYSIS FORM**

Page 1 of 2

######## **FORM 3 - INCOME ANALYSIS FORM (Continued)**

Page 2 of 2

+----------------------------+-----------------------------------------+
| **Part 2: Non-Federal      |                                         |
| Share, other Income**      |                                         |
+----------------------------+-----------------------------------------+
|                            | **Total Other Income by Source**        |
+----------------------------+-----------------------------------------+
| 9\. Applicant              |                                         |
+----------------------------+-----------------------------------------+
| 10\. State Funds           |                                         |
+----------------------------+-----------------------------------------+
| 11\. Local Funds           |                                         |
+----------------------------+-----------------------------------------+
| Other Support              |                                         |
+----------------------------+-----------------------------------------+
| 12a. Other Federal Grants  |                                         |
+----------------------------+-----------------------------------------+
| 12b. Contributions and     |                                         |
| Fundraising                |                                         |
+----------------------------+-----------------------------------------+
| 12c. Foundation Grants     |                                         |
+----------------------------+-----------------------------------------+
| 12d. Other                 |                                         |
| \_\                        |                                         |
| _\_\_\_\_\_\_\_\_\_(please |                                         |
| list)                      |                                         |
+----------------------------+-----------------------------------------+
| 12\. Subtotal Other        |                                         |
| Support                    |                                         |
+----------------------------+-----------------------------------------+
| **13. Total Other Income** |                                         |
+----------------------------+-----------------------------------------+
| **TOTAL NON-FEDERAL        |                                         |
| SHARE**                    |                                         |
|                            |                                         |
| **\[line 6, row (g) +      |                                         |
| line, 7 row (e) + line     |                                         |
| 13\]**                     |                                         |
|                            |                                         |
| **Matches line 5, column   |                                         |
| f, "Non-Federal" Totals of |                                         |
| SF 424A**                  |                                         |
+----------------------------+-----------------------------------------+
| **Comments/Explanatory     |                                         |
| Notes for Income Analysis  |                                         |
| Form (if applicable):**    |                                         |
+----------------------------+-----------------------------------------+

######## **FORM 4: COMMUNITY CHARACTERISTICS**

**Instructions to Applicants**: Service area and target population data
should reflect all counties, cities, etc., in the applicant's proposed
project. Service area data should include the total number of persons
and the percent of the total population for each characteristic. Target
population data is most often a subset of the service area data. Target
population should include the number of persons and the percent of the
total population the applicant **[targets]{.underline}** for each
characteristic. Estimates are acceptable. *Please do not utilize patient
data reported in the Uniform Data System to report target population
data.*

+------------+-----------------------+-------+-------+--------+------+
|            | **CHARACTERISTIC**    | **SE  |       | **     |      |
|            |                       | RVICE |       | TARGET |      |
|            |                       | AREA  |       | POPU   |      |
|            |                       | D     |       | LATION |      |
|            |                       | ATA** |       | DATA** |      |
|            |                       |       |       |        |      |
|            |                       | **\#  |       | **\#   |      |
|            |                       | %**   |       | %**    |      |
+------------+-----------------------+-------+-------+--------+------+
| RACE       | Asian                 |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Native Hawaiian or    |       |       |        |      |
|            | Other Pacific         |       |       |        |      |
|            | Islander              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Black or African      |       |       |        |      |
|            | American              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | American Indian or    |       |       |        |      |
|            | Alaska Native         |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | White                 |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | More than one race    |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Unreported / Refused  |       |       |        |      |
|            | to report (if         |       |       |        |      |
|            | applicable)           |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Total:                |       | **1   |        | **10 |
|            |                       |       | 00%** |        | 0%** |
+------------+-----------------------+-------+-------+--------+------+
| hispanic   | Hispanic or Latino    |       |       |        |      |
| origin     |                       |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Not Hispanic or       |       |       |        |      |
|            | Latino                |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Unreported / Refused  |       |       |        |      |
|            | to report (if         |       |       |        |      |
|            | applicable)           |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Total:                |       | **1   |        | **10 |
|            |                       |       | 00%** |        | 0%** |
+------------+-----------------------+-------+-------+--------+------+
| INCOME AS  | Below 100%            |       |       |        |      |
| A PERCENT  |                       |       |       |        |      |
| OF POVERTY |                       |       |       |        |      |
| LEVEL      |                       |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | 100-199 percent       |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | 200 percent and above |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Unknown               |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Total:                |       | **1   |        | **10 |
|            |                       |       | 00%** |        | 0%** |
+------------+-----------------------+-------+-------+--------+------+
| PRIMARY    | Medicaid/Capitated    |       |       |        |      |
| THIRD      |                       |       |       |        |      |
| PARTY      |                       |       |       |        |      |
| PAYMENT    |                       |       |       |        |      |
| SOURCE     |                       |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Medicaid/Not          |       |       |        |      |
|            | Capitated             |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Medicare              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Other Public          |       |       |        |      |
|            | Insurance             |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Private Insurance,    |       |       |        |      |
|            | including capitation  |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | None/Uninsured        |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Total:                |       | **1   |        | **10 |
|            |                       |       | 00%** |        | 0%** |
+------------+-----------------------+-------+-------+--------+------+
| SPECIAL    | Migrant/ Seasonal     |       |       |        |      |
| P          | Farmworkers and       |       |       |        |      |
| OPULATIONS | Families              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Homeless              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Residents of Public   |       |       |        |      |
|            | Housing               |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | HIVAIDS-Infected      |       |       |        |      |
|            | Persons               |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Persons with Mental   |       |       |        |      |
|            | Health/Substance      |       |       |        |      |
|            | Abuse Needs           |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | School Age Children   |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Infants Birth to 2    |       |       |        |      |
|            | years of Age          |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Women Age 25 - 44     |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Persons Age 65 and    |       |       |        |      |
|            | Older                 |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Other: (Please        |       |       |        |      |
|            | specify)              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+

########  {#section-6}

########  {#section-7}

######## **FORM 5 - PART A: SERVICES PROVIDED**

<table>
<colgroup>
<col style="width: 8%" />
<col style="width: 16%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 19%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><strong>APPLICANT’S NAME:</strong> LOCATION:</td>
</tr>
<tr class="even">
<td colspan="2">SERVICE TYPE</td>
<td>PROVIDED BY Applicant</td>
<td><p>BY REFERRAL/ Applicant</p>
<p>PAYS</p></td>
<td>BY REFERRAL/ Applicant DOESN’T PAY</td>
<td colspan="2">SERVICE TYPE</td>
<td>PROVIDED BY Applicant</td>
<td><p>BY REFERRAL/ Applicant</p>
<p>PAYS</p></td>
<td><p>BY REFERRAL/ Applicant</p>
<p>DOESN’T PAY</p></td>
</tr>
<tr class="odd">
<td rowspan="10">PRIMARY MEDICAL CARE SERVICES</td>
<td>General Primary Medical Care</td>
<td></td>
<td></td>
<td></td>
<td rowspan="9">OTHER SERVICES</td>
<td>Environmental Health</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Diagnostic Laboratory</td>
<td></td>
<td></td>
<td></td>
<td>Hearing Screening</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Diagnostic X-Ray</td>
<td></td>
<td></td>
<td></td>
<td>Nutrition (not WIC)</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Diagnostic Tests/Screens</td>
<td></td>
<td></td>
<td></td>
<td>Occ./Voc. Therapy</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Urgent Medical Care</td>
<td></td>
<td></td>
<td></td>
<td>Physical Therapy</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>24-Hour Coverage</td>
<td></td>
<td></td>
<td></td>
<td>Pharmacy</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Family Planning</td>
<td></td>
<td></td>
<td></td>
<td>Podiatry</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>HIV Testing</td>
<td></td>
<td></td>
<td></td>
<td>Vision Screening</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Immunizations</td>
<td></td>
<td></td>
<td></td>
<td>WIC</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Following Hospitalized Patients</td>
<td></td>
<td></td>
<td></td>
<td rowspan="16">ENABLING SERVICES</td>
<td>Case Management</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td rowspan="2">OB/GYN CARE</td>
<td>Gynecological Care</td>
<td></td>
<td></td>
<td></td>
<td>Child Care</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Obstetrical Care</td>
<td></td>
<td></td>
<td></td>
<td>Discharge Planning</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td rowspan="3">SPECIALTY SERVICES</td>
<td>TB Therapy</td>
<td></td>
<td></td>
<td></td>
<td>Eligibility Assistance</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Other</td>
<td></td>
<td></td>
<td></td>
<td>Emp./Ed. Counseling</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Other</td>
<td></td>
<td></td>
<td></td>
<td>Food Bank/Meals</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td rowspan="4">DENTAL SERVICES</td>
<td>Preventive</td>
<td></td>
<td></td>
<td></td>
<td>Health Education</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Restorative</td>
<td></td>
<td></td>
<td></td>
<td>Homemaker/Aide</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Emergency</td>
<td></td>
<td></td>
<td></td>
<td>Housing Assistance</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Other</td>
<td></td>
<td></td>
<td></td>
<td>Translation</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td rowspan="6">MENTAL HEALTH SERVICES</td>
<td>Treatment/Counseling</td>
<td></td>
<td></td>
<td></td>
<td>Nursing Home and Other Placement</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Developmental Screening</td>
<td></td>
<td></td>
<td></td>
<td>Outreach</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>24-Hour Crisis</td>
<td></td>
<td></td>
<td></td>
<td>Transportation</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Other Mental Health</td>
<td></td>
<td></td>
<td></td>
<td>Other:</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Substance Abuse</td>
<td></td>
<td></td>
<td></td>
<td>Other:</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Other Substance Abuse</td>
<td></td>
<td></td>
<td></td>
<td>Other:</td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

##### FORM 5 -- Part B: SERVICE SITES 

+----------------------------------+-----------------------------------+
| **SITE #1**                      | SITE #2                           |
+----------------------------------+-----------------------------------+
| G Year-Round G Seasonal         | G Year-Round G Seasonal          |
| Full-Time  Part-Time            | Full-Time  Part-Time             |
|                                  |                                   |
| \# of hours per week services    | \# of hours per week services are |
| are available at the site:       | available at the site:            |
|                                  |                                   |
| Date site was opened:            | Date site was opened:             |
|                                  |                                   |
| Name of service site:            | Name of service site:             |
|                                  |                                   |
| Physical Address:                | Physical Address:                 |
|                                  |                                   |
| City State Zip (9 digit          | City State Zip (9 digit required) |
| required)                        |                                   |
|                                  | Phone No. Fax No.                 |
| Phone No. Fax No.                |                                   |
|                                  | Congressional District:           |
| Congressional District:          |                                   |
|                                  | County Name:                      |
| County Name:                     |                                   |
|                                  | Service Area by census tract:     |
| Service Area by census tract:    |                                   |
|                                  | Urban/Rural/Sparsely Populated:   |
| Urban/Rural/Sparsely Populated:  |                                   |
|                                  | Other HRSA Funding Sources:       |
| Other HRSA Funding Sources:      |                                   |
+----------------------------------+-----------------------------------+
| SITE #3                          | SITE #4                           |
+----------------------------------+-----------------------------------+
| G Year-Round G Seasonal         | G Year-Round G Seasonal          |
| Full-Time  Part-Time            | Full-Time  Part-Time             |
|                                  |                                   |
| \# of hours per week services    | \# of hours per week services are |
| are available at the site:       | available at the site:            |
|                                  |                                   |
| Date site was opened:            | Date site was opened:             |
|                                  |                                   |
| Name of service site:            | Name of service site:             |
|                                  |                                   |
| Physical Address:                | Physical Address:                 |
|                                  |                                   |
| City State Zip (9 digit          | City State Zip (9 digit required) |
| required)                        |                                   |
|                                  | Phone No. Fax No.                 |
| Phone No. Fax No.                |                                   |
|                                  | Congressional District:           |
| Congressional District:          |                                   |
|                                  | County Name:                      |
| County Name:                     |                                   |
|                                  | Service Area by census tract:     |
| Service Area by census tract:    |                                   |
|                                  | Urban/Rural/Sparsely Populated:   |
| Urban/Rural/Sparsely Populated:  |                                   |
|                                  | Other HRSA Funding Sources:       |
| Other HRSA Funding Sources:      |                                   |
+----------------------------------+-----------------------------------+
| SITE #5                          | SITE #6                           |
+----------------------------------+-----------------------------------+
| G Year-Round G Seasonal         | G Year-Round G Seasonal          |
| Full-Time  Part-Time            | Full-Time  Part-Time             |
|                                  |                                   |
| \# of hours per week services    | \# of hours per week services are |
| are available at the site:       | available at the site:            |
|                                  |                                   |
| Date site was opened:            | Date site was opened:             |
|                                  |                                   |
| Name of service site:            | Name of service site:             |
|                                  |                                   |
| Physical Address:                | Physical Address:                 |
|                                  |                                   |
| City State Zip (9 digit          | City State Zip (9 digit required) |
| required)                        |                                   |
|                                  | Phone No. Fax No.                 |
| Phone No. Fax No.                |                                   |
|                                  | Congressional District:           |
| Congressional District:          |                                   |
|                                  | County Name:                      |
| County Name:                     |                                   |
|                                  | Service Area by census tract:     |
| Service Area by census tract:    |                                   |
|                                  | Urban/Rural/Sparsely Populated:   |
| Urban/Rural/Sparsely Populated:  |                                   |
|                                  | Other HRSA Funding Sources:       |
| Other HRSA Funding Sources:      |                                   |
+----------------------------------+-----------------------------------+

##### FORM 5 - PART C OTHER ACTIVITIES/LOCATIONS

+----------------------------------+-----------------------------------+
| **ACTIVITY/LOCATION #1**         | **ACTIVITY/LOCATION** #2          |
+----------------------------------+-----------------------------------+
| TYPE/DESCRIPTION OF ACTIVITY:    | TYPE/DESCRIPTION OF ACTIVITY:     |
|                                  |                                   |
| TYPE OF LOCATION(S) WHERE        | TYPE OF LOCATION(S) WHERE         |
| ACTIVITY IS CONDUCTED:           | ACTIVITY IS CONDUCTED:            |
+----------------------------------+-----------------------------------+
| **ACTIVITY/LOCATION** #3         | **ACTIVITY/LOCATION** #4          |
+----------------------------------+-----------------------------------+
| TYPE/DESCRIPTION OF ACTIVITY:    | TYPE/DESCRIPTION OF ACTIVITY:     |
|                                  |                                   |
| TYPE OF LOCATION(S) WHERE        | TYPE OF LOCATION(S) WHERE         |
| ACTIVITY IS CONDUCTED:           | ACTIVITY IS CONDUCTED:            |
+----------------------------------+-----------------------------------+
| **ACTIVITY/LOCATION** #5         | **ACTIVITY/LOCATION** #6          |
+----------------------------------+-----------------------------------+
| TYPE/DESCRIPTION OF ACTIVITY:    | TYPE/DESCRIPTION OF ACTIVITY:     |
|                                  |                                   |
| TYPE OF LOCATION(S) WHERE        | TYPE OF LOCATION(S) WHERE         |
| ACTIVITY IS CONDUCTED:           | ACTIVITY IS CONDUCTED:            |
+----------------------------------+-----------------------------------+

######## **FORM 6 -- PART A: CURRENT BOARD MEMBER CHARACTERISTICS** 

+--------------------+---------+-----------+--------+-----+-----------+
| **BOARD MEMBER     | **BOARD | **O       | **IN   | **L | **YEARS   |
| NAME**             | OFFICE  | CCUPATION | DICATE | IVE | OF        |
|                    | HELD**  | /\        | IF     | (L) | C         |
|                    |         | AREA OF   | USER   | OR  | ONTINUOUS |
|                    |         | EX        | OF     | W   | BOARD     |
|                    |         | PERTISE** | HEALTH | ORK | SERVICE** |
|                    |         |           | CENTER | (W) |           |
|                    |         |           | SERV   | IN  |           |
|                    |         |           | ICES** | S   |           |
|                    |         |           |        | ERV |           |
|                    |         |           | **(YES | ICE |           |
|                    |         |           | /NO)** | ARE |           |
|                    |         |           |        | A** |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 1\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 2\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 3\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 4\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 5\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 6\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 7\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 8\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 9\.                |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 10\.               |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 11\.               |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 12\.               |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 13\.               |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+
| 14\.               |         |           |        |     |           |
+--------------------+---------+-----------+--------+-----+-----------+

Indicate \# Board Members by Sex: F = \_\_\_\_\_\_\_ M = \_\_\_\_\_\_

Indicate \# Board Members by Race/Ethnicity:

White: \_\_\_\_\_\_\_ Hispanic or Latino: \_\_\_\_\_\_\_ Black/African
American: \_\_\_\_\_\_

Asian/Pacific Islander\_\_\_\_\_\_ American Indian & Alaska
Native:\_\_\_\_\_

**NOTES: (1) Please indicate if a board member is a special population
representative (MHC, HCH, PHPC).**

> **(2) MHC, HCH, and/or PHPC applicants requesting a waiver of the
> governance requirements must complete Form 6 -- Part B and describe
> any alternative arrangement for addressing Board requirements
> including the mechanism for receiving consumer input.**
>
> **(3) Tribal entities are exempt from Governance Requirements.**
>
> **(4)** Add additional pages if needed.

##### FORM 8- Part A: HEALTH CENTER AFFILIATION CERTIFICATION

**(MUST BE COMPLETED BY ALL CHC and/or MHC APPLICANTS)**

**Organization: [     ]{.underline} UDS \#** [     ]{.underline}

*(where applicable)*

**Does your organization have any of the following arrangements with
another organization? NOTE: [You must complete a checklist for EACH
organization with which you have any of the following
arrangements]{.underline}.**

NO *(Submit only this page with application, no other documents
necessary)*

YES *(Please check all that apply and complete and submit FORM 8 -- Part
B)*

> a) Contract or sub-award for a substantial portion of the proposed
> project
>
> b) Memorandum of Understanding (MOU)/Agreement (MOA) for a substantial
> portion of the proposed project
>
> c) Contract with another organization or individual contract for core
> primary care providers
>
> d) Contract with another organization for staffing health center
>
> e) Contract with another organization for the Chief Medical Officer
> (CMO) or Chief Financial Officer (CFO)
>
> f) Merger with another organization
>
> g) Parent Subsidiary Model arrangement
>
> h) Acquisition by another organization
>
> i) Establishment of a New Entity (e.g., Network corporation)

Name of Affiliating Organization:      

Address:      

     

![](media/image1.wmf){width="1.4590277777777778in"
height="0.28958333333333336in"}![](media/image1.wmf){width="1.457638888888889in"
height="0.29097222222222224in"}![](media/image1.wmf){width="1.457638888888889in"
height="0.29097222222222224in"}

+---------------------------------------------------+------+----+------+
| **STAFFING:**                                     |      | *  | **   |
|                                                   |      | *Y | NO** |
|                                                   |      | ES |      |
|                                                   |      | ** |      |
+---------------------------------------------------+------+----+------+
| 1\) The center directly employs the CFO, CMO and  |      |    |      |
| the core staff of full-time primary care          |      |    |      |
| providers.                                        |      |    |      |
+---------------------------------------------------+------+----+------+
| 2\) The center directly employs all non-provider  |      |    |      |
| health center staff.                              |      |    |      |
+---------------------------------------------------+------+----+------+
| > If NO to question 1 or 2, does the CEO of the   |      |    |      |
| > center retains the authority to select and      |      |    |      |
| > dismiss the CFO and CMO as well as other staff  |      |    |      |
| > assigned to the center? Please cite reference   |      |    |      |
| > document and page #.                            |      |    |      |
+---------------------------------------------------+------+----+------+
| **GOVERNANCE:**                                   |      | *  | **   |
|                                                   |      | *Y | NO** |
|                                                   |      | ES |      |
|                                                   |      | ** |      |
+---------------------------------------------------+------+----+------+
| 3\) The arrangements presented in the affiliation |      |    |      |
| agreements, as defined in FORM 8 -- Part A, do    |      |    |      |
| not compromise the Board's authorities or limit   |      |    |      |
| its legislative and regulatory mandated functions |      |    |      |
| and responsibilities as defined below. *(Examples |      |    |      |
| of compromising arrangements are: overriding      |      |    |      |
| approval or veto authority by another entity;     |      |    |      |
| dual majority requirements; super-majority        |      |    |      |
| requirements; or hiring and dismissal of the      |      |    |      |
| CEO).*                                            |      |    |      |
+---------------------------------------------------+------+----+------+
|                                                   | R    |    | Page |
|                                                   | efer |    | \#   |
|                                                   | ence |    |      |
|                                                   | Docu |    |      |
|                                                   | ment |    |      |
+---------------------------------------------------+------+----+------+
| -   board composition                             | >    |    | >    |
|                                                   |      |    |      |
+---------------------------------------------------+------+----+------+
| -   executive committee function and composition  | >    |    | >    |
|                                                   |      |    |      |
+---------------------------------------------------+------+----+------+
| -   selection of board chairperson                | >    |    | >    |
|                                                   |      |    |      |
+---------------------------------------------------+------+----+------+
| -   selection of members                          | >    |    | >    |
|                                                   |      |    |      |
+---------------------------------------------------+------+----+------+
| -   strategic planning                            | >    |    | >    |
|                                                   |      |    |      |
+---------------------------------------------------+------+----+------+
| -   approval of the annual budget of the center   | >    |    | >    |
|                                                   |      |    |      |
+---------------------------------------------------+------+----+------+
| -   directly employs, selects/dismisses and       | >    |    | >    |
|     evaluates the Chief Executive                 |      |    |      |
|     Officer/Executive Director                    |      |    |      |
+---------------------------------------------------+------+----+------+
| -   adoption of policies and procedures for       | >    |    | >    |
|     personnel and financial management            |      |    |      |
+---------------------------------------------------+------+----+------+
| -   establishes center priorities                 | >    |    | >    |
|                                                   |      |    |      |
+---------------------------------------------------+------+----+------+
| -   establishes eligibility requirements for      | >    |    | >    |
|     partial payment for services                  |      |    |      |
+---------------------------------------------------+------+----+------+
| -   provides for an independent audit             | >    |    | >    |
|                                                   |      |    |      |
+---------------------------------------------------+------+----+------+
| -   evaluation of center activities               | >    |    | >    |
|                                                   |      |    |      |
+---------------------------------------------------+------+----+------+
| -   adoption of center's health care policies     | >    |    | >    |
|     including scope and availability of services, |      |    |      |
|     location, hours of operation and quality of   |      |    |      |
|     care audit procedures                         |      |    |      |
+---------------------------------------------------+------+----+------+
| -   existence of a conflict of interest policy    | >    |    | >    |
|                                                   |      |    |      |
+---------------------------------------------------+------+----+------+
| -   contains appropriate provisions around the    | >    |    | >    |
|     activities to be performed, time, schedules,  |      |    |      |
|     the policies and procedures to be followed in |      |    |      |
|     carrying out the agreement, and the maximum   |      |    |      |
|     amount of money for which the grantee may     |      |    |      |
|     become liable to the contractor under the     |      |    |      |
|     agreement;                                    |      |    |      |
+---------------------------------------------------+------+----+------+
| -   requires the contractor to maintain           | >    |    | >    |
|     appropriate financial, program and property   |      |    |      |
|     management systems and records in accordance  |      |    |      |
|     with 45 CFR Part 74 and provides the center,  |      |    |      |
|     DHHS and the U.S. Comptroller General with    |      |    |      |
|     access to such records;                       |      |    |      |
+---------------------------------------------------+------+----+------+
| -   requires the submission of financial and      | >    |    | >    |
|     programmatic reports to the health center;    |      |    |      |
+---------------------------------------------------+------+----+------+
| -   complies with Federal procurement standards   | >    |    | >    |
|     or grant requirements including conflict of   |      |    |      |
|     interest standards;                           |      |    |      |
+---------------------------------------------------+------+----+------+
| -   subject to termination (with administrative,  | >    |    | >    |
|     contractual and legal remedies) in the event  |      |    |      |
|     of breach by the contractor.                  |      |    |      |
+---------------------------------------------------+------+----+------+
| **CONTRACTING:**                                  | **Y  |    | **   |
|                                                   | ES** |    | NO** |
+---------------------------------------------------+------+----+------+
| 6\) The center has justified the performance of   |      |    |      |
| the work by a third party. Please cite reference  |      |    |      |
| doc and page #.                                   |      |    |      |
+---------------------------------------------------+------+----+------+
| 7\) Written affiliation agreement(s) comply with  |      |    |      |
| current Department of Health and Human Services   |      |    |      |
| (HHS) policies.                                   |      |    |      |
+---------------------------------------------------+------+----+------+
|                                                   |      |    |      |
+---------------------------------------------------+------+----+------+

##### FORM 8 -- Part B: HEALTH CENTER AFFILIATION CHECKLIST

**FORM 9: ANNUAL EMERGENCY PREPAREDNESS AND MANAGEMENT (EPM) REPORT**

+-----------------------------------------------------------+----+----+
| ## SECTION I - EMERGENCY PREPAREDNESS AND MANAGEMENT PLAN | *  | ** |
|                                                           | *Y | NO |
|                                                           | ES | ** |
|                                                           | ** |    |
+-----------------------------------------------------------+----+----+
| Has your organization conducted a thorough Hazards        |    |    |
| Vulnerability Assessment?                                 |    |    |
|                                                           |    |    |
| *If yes, the date completed:\_\_\_\_\_\_*                 |    |    |
+-----------------------------------------------------------+----+----+
| Does your organization have a written EPM plan?           |    |    |
|                                                           |    |    |
| ***If Yes, the date most recent EPM plan was approved by  |    |    |
| your Board*:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**          |    |    |
|                                                           |    |    |
| ***If No, skip to Readiness section below*. Date**        |    |    |
+-----------------------------------------------------------+----+----+
| Does the EPM plan specifically address the four disaster  |    |    |
| phases? Mitigation?                                       |    |    |
|                                                           |    |    |
| Preparedness?                                             |    |    |
|                                                           |    |    |
| Response?                                                 |    |    |
|                                                           |    |    |
| Recovery?                                                 |    |    |
+-----------------------------------------------------------+----+----+
|                                                           |    |    |
+-----------------------------------------------------------+----+----+
|                                                           |    |    |
+-----------------------------------------------------------+----+----+
|                                                           |    |    |
+-----------------------------------------------------------+----+----+
| Is your EPM plan integrated into your local/regional      |    |    |
| emergency plan?                                           |    |    |
+-----------------------------------------------------------+----+----+
| If no, has your organization attempted to participate     |    |    |
| with local/regional emergency planners?                   |    |    |
+-----------------------------------------------------------+----+----+
| Does the EPM plan address your capacity to render mass    |    |    |
| immunization/prophylaxis?                                 |    |    |
+-----------------------------------------------------------+----+----+
| ## SECTION II - READINESS                                 | *  | ** |
|                                                           | *Y | NO |
|                                                           | ES | ** |
|                                                           | ** |    |
+-----------------------------------------------------------+----+----+
| Does your organization include alternatives for providing |    |    |
| primary care to your current patient population if you    |    |    |
| are unable to do so during an emergency?                  |    |    |
+-----------------------------------------------------------+----+----+
| Does your organization conduct annual planned drills?     |    |    |
+-----------------------------------------------------------+----+----+
| Does your organization's staff receive periodic training  |    |    |
| on disaster preparedness?                                 |    |    |
+-----------------------------------------------------------+----+----+
| Will the organization be required to deploy staff to      |    |    |
| non-Health Center sites/locations according to the        |    |    |
| emergency preparedness plan for the local community?      |    |    |
+-----------------------------------------------------------+----+----+
| Does your organization have arrangements with Federal,    |    |    |
| State, and/or local agencies for reporting of data?       |    |    |
+-----------------------------------------------------------+----+----+
| Does your organization have a back-up communication       |    |    |
| system? Internal?                                         |    |    |
|                                                           |    |    |
| External?                                                 |    |    |
+-----------------------------------------------------------+----+----+
|                                                           |    |    |
+-----------------------------------------------------------+----+----+
| Does your organization coordinate with other systems of   |    |    |
| care to provide an integrated emergency response?         |    |    |
+-----------------------------------------------------------+----+----+
| Has your organization been designated to serve as a point |    |    |
| of distribution (POD) for providing antibiotics,          |    |    |
| vaccines, and medical supplies?                           |    |    |
+-----------------------------------------------------------+----+----+
| Has your organization implemented measures to prevent     |    |    |
| financial/revenue and facilities loss due to an           |    |    |
| emergency? (e.g. insurance coverage for short-term        |    |    |
| closure)                                                  |    |    |
+-----------------------------------------------------------+----+----+
| Does your organization have an off-site back up of your   |    |    |
| information technology system?                            |    |    |
+-----------------------------------------------------------+----+----+
| Does your organization have a designated EPM coordinator? |    |    |
+-----------------------------------------------------------+----+----+

#  {#section-8}

#  {#section-9}

#  {#section-10}

#  {#section-11}

# APPENDIX D

# INSTRUCTIONS FOR THE BUDGET PRESENTATION 

## GUIDELINES FOR COMPLETION OF THE BUDGET PRESENTATION

This section explains the requirements for developing and presenting the
Standard Form 424A: Budget Information for Non-Construction Programs and
the Budget Justification as part of the application for Federal support
under the Health Center Program. For instructions on completing Form 2:
Staffing Profile and Form 3: Income Analysis Form, which support the 424
A and Budget Justification, please see Appendix C.

Applicants should note that in the formulation of their budget
presentation, per section 330(e)(5)(A) of the PHS Act (42 U.S.C. 254b),
the amount of grant funds made in any fiscal year may not exceed the
amount by which the costs of operation of the center in such fiscal year
exceed the total of: State, local, and other operational funding
provided to the center; and the fees, premiums, and third-party
reimbursements, which the center may reasonably be expected to receive
for its operations in such fiscal year.

[Guidelines for Completing Standard Form 424A, Sections A-F]{.underline}

Please complete Sections A, B, E, and F (if F is applicable) of the PHS
5161-1: Standard Form (SF) 424A -- Budget Information for
Non-Constructions Programs (included as part of the Grants.Gov
electronic application). As necessary, utilize a separate column on the
SF 424A section B and E to list funds by type of health center program
(Community: CHC, Migrant: MHC, Homeless: HCH, and/or Public Housing:
PHPC). The budget should clearly indicate cost for each program. **All
budgets should be prepared for a 12-month period [based on the budget
period end date]{.underline}.** The SAC-Additional Areas budget should
be based upon the recommended level of future support (Applicants
currently receiving section 330 funds should reference Item 13 or Item
19 of their Notice of Grant Award - commonly referred to as ongoing
target level of Federal support).

-   The Federal cost principles apply only to Federal grant funds, as
    stated in the Health Centers Consolidation Act of 1996.

-   Amounts in the budget(s) must be rounded to the nearest whole
    dollar.

The following guidelines should be used by the applicant in the
completion of the SF-424A. In addition, please review the sample 424A
located in this Appendix.

**Section A - Budget Summary**

> Section A (under "New or Revised Budget") should reflect the proposed
> budget for the first 12-month budget period broken down by each
> section 330 program for which the applicant is requesting funding
> (e.g. MHC on row 1, CHC on row 2, etc. as applicable); Complete
> columns (e), (f), and (g). **Please note that for the purposes of this
> application, column (e) "Federal" refers to only the Federal section
> 330 grant funding and not other Federal grant funding that applicant
> may receive.**

**Section B - Budget categories**

This section is a summary of all budget calculations and information for
the project for the first 12-month budget period. Each line represents a
distinct object class category that should be addressed in the budget
justification (see below). Each column should reflect the total budget
by object class for each section 330 program for which the applicant is
requesting funding (e.g. MHC in column 1, CHC in column 2, etc. as
applicable). Note that row 7 "Program Income" should be consistent with
the "Total Program Income" presented in Form 3 -- Income Analysis.

**Section E - Budget estimates of federal funds needed for balance of
the project**

Use the columns in Section E (titled: "(b) First, (c) Second, etc.) to
present the projected Federal section 330 funding requests for the
2^nd^, 3^rd^, 4^th^, and 5^th^ years of the project period (as
applicable) for each section 330 program for which funding is requested
(e.g. MHC on row 1, CHC on row 2, etc. as applicable). **The requested
amounts for the remainder of the project period MUST NOT exceed the
requested level of funding for the first year of the project period.**

**Section F -- other budget information ([only if
applicable]{.underline})**

***Line 21:*** Use this space to explain amounts for individual direct
object-class cost categories that may appear to be out of the ordinary.

***Line 22:*** Enter the type of indirect rate (provisional,
predetermined, final or fixed ) that will be in effect during the
funding period, the estimated amount of the base to which the rate is
applied, and the total indirect expense.

***Line 23:*** Provide any other explanations or comments deemed
necessary.

[Guidelines for the Budget Justification]{.underline}

A detailed budget justification in line-item format must be completed
for each 12-month period requested for Federal funding. Applicants may
request up to a 5 year project period. **Only the first year of the
budget justification should itemize revenues and expenses for each type
of health center program for which funding is requested (Community: CHC,
Migrant: MHC, Homeless: HCH, and/or Public Housing: PHPC).** In
addition, if there are budget items for which costs are shared with
other programs (e.g., HRSA programs or an independent home health
program administered by the applicant organization), the basis for the
allocation of costs between federally supported programs and other
independent programs must be explained.  Attach the budget justification
in the "Budget Narrative Attachment Form" section of the Grants.Gov
electronic application.

The following guidelines should be used by the applicant in the
development of the budget justification. In addition, please review the
sample budget justification located in this Appendix.

**Personnel Costs:** Personnel costs (salaries and wages) should be
explained by listing key management staff and all other FTEs who will be
supported from funds, position title, percent full time equivalency,
annual salary, and the exact amount requested for each year. *Please
reference "Form 2: Staffing Profile" as justification for dollar
figures.*

**Fringe Benefits:** List the components that comprise the fringe
benefit rate, for example health insurance, taxes, unemployment
insurance, life insurance, retirement plan, tuition reimbursement. The
fringe benefits should be directly proportional to that portion of
personnel costs that are allocated for the project.

**Equipment:** "Equipment\" is defined as an article of nonexpendable,
tangible personal property having a useful life of more than one year
and an acquisition cost, which equals or exceeds the lesser of (a) the
capitalization level established by the organization for the financial
statement purposes, or (b) \$5,000. Identify each piece of equipment
that meets this definition and identify the cost per item. Also, provide
a justification to explain why the item(s) are needed for this project.
If your organization's capitalization level is lower than the Federal
amount of \$5,000 per item please submit a statement to explain. Please
note that most technological purchases and furniture items will be
identified under the "Supplies" line item because of the Federal dollar
limitation.

**Supplies:** List the items that the project will need for each budget
period. In this category, separate office supplies from medical and
educational (e.g., continuing medical education) purchases. Office
supplies could include paper, pencils, and the like; medical supplies
are syringes, blood tubes, plastic gloves, etc., and educational
supplies may be pamphlets and educational videotapes. Remember, they
must be listed separately.

**Travel:** List travel costs according to local and long distance
travel. For local travel, the mileage rate, number of miles, reason for
travel and staff member/consumers/board members completing the travel
should be outlined. The budget should also reflect the travel expenses
associated with participating in meetings and other proposed trainings
or workshops.

**Other:** Put all costs that do not fit into any other category into
this category and provide an explanation of each cost in this category.
In some cases, grantee rent, utilities and insurance fall under this
category if they are not included in an approved indirect cost rate.

**Contractual:** To the extent possible, all contract budgets and
justifications should be standardized, and contract budgets should be
presented by using the same object class categories contained in the
Standard Form 424A. Provide a clear explanation as to the purpose of
each contract, how the costs were estimated, and the specific contract
deliverables. Please list both Patient-Care and Non-Patient Care
contracts.

**Indirect Costs:** Indirect costs are those costs incurred for common
or joint objectives which cannot be readily identified but are necessary
to the operations of the organization, e.g., the cost of operating and
maintaining facilities, depreciation, and administrative salaries. For
institutions subject to OMB Circular A-122, the term "facilities and
administration" is used to denote indirect costs. If an organization
applying for an assistance award does not have an indirect cost rate,
the applicant may wish to obtain one through HHS's Division of Cost
Allocation (DCA).  Visit DCA's website at: <http://rates.psc.gov/> to
learn more about rate agreements, the process for applying for them, and
the regional offices which negotiate them.

If an organization is applying for Federal assistance and it does not
have a "Federally Negotiated Indirect Costs (IDC) Rate Agreement" all
costs will be considered direct costs until a rate agreement is
negotiated with a Federal cognizant agency and provided to HRSA to
review as part of the budget request. If the application is funded, HRSA
will reallocate any amount identified under the IDC line item budget to
the "Other" line item and request a revised budget, which clearly
identifies how these funds will be expended under the grant until the
grantee can provide an approved IDC Rate Agreement. **For organizations
that do have a previously negotiated Federal indirect cost rates, these
will be accepted but must be included/denoted in the budget and the
current Federal indirect cost rate agreement should be attached in
Attachment 13: "Other Relevant Documents."**

###### SAMPLE PHS FORM 5161-1: SF 424A FOR SERVICE AREA COMPETITION (First Page Only) 

+---+---------------+------+-------+------+-------+--------+----------+
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| B |               |      |       |      |       |        |          |
| U |               |      |       |      |       |        |          |
| D |               |      |       |      |       |        |          |
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| E |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| I |               |      |       |      |       |        |          |
| N |               |      |       |      |       |        |          |
| F |               |      |       |      |       |        |          |
| O |               |      |       |      |       |        |          |
| R |               |      |       |      |       |        |          |
| M |               |      |       |      |       |        |          |
| A |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| I |               |      |       |      |       |        |          |
| O |               |      |       |      |       |        |          |
| N |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| N |               |      |       |      |       |        |          |
| o |               |      |       |      |       |        |          |
| n |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| C |               |      |       |      |       |        |          |
| o |               |      |       |      |       |        |          |
| n |               |      |       |      |       |        |          |
| s |               |      |       |      |       |        |          |
| t |               |      |       |      |       |        |          |
| r |               |      |       |      |       |        |          |
| u |               |      |       |      |       |        |          |
| c |               |      |       |      |       |        |          |
| t |               |      |       |      |       |        |          |
| i |               |      |       |      |       |        |          |
| o |               |      |       |      |       |        |          |
| n |               |      |       |      |       |        |          |
| P |               |      |       |      |       |        |          |
| r |               |      |       |      |       |        |          |
| o |               |      |       |      |       |        |          |
| g |               |      |       |      |       |        |          |
| r |               |      |       |      |       |        |          |
| a |               |      |       |      |       |        |          |
| m |               |      |       |      |       |        |          |
| s |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| S |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| C |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| I |               |      |       |      |       |        |          |
| O |               |      |       |      |       |        |          |
| N |               |      |       |      |       |        |          |
| A |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| B |               |      |       |      |       |        |          |
| U |               |      |       |      |       |        |          |
| D |               |      |       |      |       |        |          |
| G |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| S |               |      |       |      |       |        |          |
| U |               |      |       |      |       |        |          |
| M |               |      |       |      |       |        |          |
| M |               |      |       |      |       |        |          |
| A |               |      |       |      |       |        |          |
| R |               |      |       |      |       |        |          |
| Y |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | Grant Program | Cat  | Esti  |      | New   |        |          |
|   |               | alog | mated |      | or    |        |          |
|   | Function or   | of   | U     |      | Re    |        |          |
|   |               |      | nobli |      | vised |        |          |
|   | Activity      | Fed  | gated |      | B     |        |          |
|   |               | Dome | Funds |      | udget |        |          |
|   | \(a\)         | stic |       |      |       |        |          |
|   |               |      |       |      |       |        |          |
|   |               | As   |       |      |       |        |          |
|   |               | sist |       |      |       |        |          |
|   |               | No.  |       |      |       |        |          |
|   |               |      |       |      |       |        |          |
|   |               | \    |       |      |       |        |          |
|   |               | (b\) |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   |               |      | Fe    | Non  | Fe    | Non‑F  | Total    |
|   |               |      | deral | ‑Fed | deral | ederal |          |
|   |               |      |       | eral |       |        | \(g\)    |
|   |               |      | \(c\) |      | \(e\) | \(f\)  |          |
|   |               |      |       | \    |       |        |          |
|   |               |      |       | (d\) |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 1 | **Migrant     | 93   |       |      | > \   | >      | > \$4    |
| \ | Health        | .224 |       |      | $1,25 |  \$3,4 | ,705,817 |
| . | Centers - 330 |      |       |      | 3,113 | 52,704 |          |
|   | (g)**         |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 2 | **Community   | 93   |       |      | > \   | >      | > \$10   |
| \ | Health        | .224 |       |      | $2,75 |  \$7,5 | ,357,820 |
| . | Centers- 330  |      |       |      | 8,334 | 99,486 |          |
|   | (e)**         |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 3 |               |      |       |      |       |        |          |
| \ |               |      |       |      |       |        |          |
| . |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 4 |               |      |       |      |       |        |          |
| \ |               |      |       |      |       |        |          |
| . |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 5 | TOTALS        |      |       |      | > \   | >      | > \$15   |
| \ |               |      |       |      | $4,01 | \$11,0 | ,063,637 |
| . |               |      |       |      | 1,447 | 52,190 |          |
+---+---------------+------+-------+------+-------+--------+----------+
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| S |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| C |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| I |               |      |       |      |       |        |          |
| O |               |      |       |      |       |        |          |
| N |               |      |       |      |       |        |          |
| B |               |      |       |      |       |        |          |
|   |               |      |       |      |       |        |          |
| - |               |      |       |      |       |        |          |
| B |               |      |       |      |       |        |          |
| U |               |      |       |      |       |        |          |
| D |               |      |       |      |       |        |          |
| G |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| C |               |      |       |      |       |        |          |
| A |               |      |       |      |       |        |          |
| T |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| G |               |      |       |      |       |        |          |
| O |               |      |       |      |       |        |          |
| R |               |      |       |      |       |        |          |
| I |               |      |       |      |       |        |          |
| E |               |      |       |      |       |        |          |
| S |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 6 | Object Class  | **G  |       |      |       |        | Total    |
| \ | Category      | rant |       |      |       |        |          |
| . |               | Pro  |       |      |       |        | \(5\)    |
|   |               | gram |       |      |       |        |          |
|   |               | Func |       |      |       |        |          |
|   |               | tion |       |      |       |        |          |
|   |               | or   |       |      |       |        |          |
|   |               | Ac   |       |      |       |        |          |
|   |               | tivi |       |      |       |        |          |
|   |               | ty** |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   |               | \    | \(2\) |      |       |        |          |
|   |               | (1\) | **C   |      |       |        |          |
|   |               | **M  | ommun |      |       |        |          |
|   |               | igra | ity** |      |       |        |          |
|   |               | nt** |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | a\. Personnel | >    | > \   |      |       |        | > \$9    |
|   |               |  \$2 | $6,46 |      |       |        | ,401,600 |
|   |               | ,937 | 4,540 |      |       |        |          |
|   |               | ,060 |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | b\. Fringe    | > \  | > \   |      |       |        | > \$2    |
|   | Benefits      | $676 | $1,48 |      |       |        | ,164,665 |
|   |               | ,241 | 8,424 |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | c\. Travel    | >    | > \$9 |      |       |        | > \      |
|   |               | \$41 | 2,276 |      |       |        | $134,200 |
|   |               | ,924 |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | d\. Equipment | > \  | >     |      |       |        | > \      |
|   |               | $211 |  \$46 |      |       |        | $675,557 |
|   |               | ,044 | 4,513 |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | e\. Supplies  | > \  | >     |      |       |        | > \      |
|   |               | $146 |  \$32 |      |       |        | $470,000 |
|   |               | ,828 | 3,172 |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | f\.           | > \  | >     |      |       |        | > \      |
|   | Contractual   | $294 |  \$64 |      |       |        | $941,200 |
|   |               | ,031 | 7,169 |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | g\.           |      |       |      |       |        |          |
|   | Construction  |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | h\. Other     | > \  | >     |      |       |        | > \$1    |
|   |               | $398 |  \$87 |      |       |        | ,276,415 |
|   |               | ,752 | 7,663 |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | i\. Total     |      |       |      |       |        |          |
|   | Direct        |      |       |      |       |        |          |
|   | Charges (sum  |      |       |      |       |        |          |
|   | of 6a‑6h)     |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | j\. Indirect  |      |       |      |       |        |          |
|   | Charges       |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | k\. TOTALS    | >    | > \$  |      |       |        | > \$15   |
|   | (sum of 6i    |  \$4 | 10,35 |      |       |        | ,063,637 |
|   | and 6j)       | ,705 | 7,757 |      |       |        |          |
|   |               | ,880 |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 7 | Program       | >    | > \   |      |       |        | > \$10   |
| \ | Income        |  \$3 | $7,25 |      |       |        | ,545,540 |
| . |               | ,294 | 1,113 |      |       |        |          |
|   |               | ,427 |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+

Standard Form 424A (7-97

Prescribed by OMB Circular A-10

## SAMPLE BUDGET JUSTIFICATION

Instructions: The sample budget justification (by line-item) shown below
is provided as an example and [broad outline]{.underline}. Please note
that a detailed budget justification is required for all items within
each category for which funds are requested as applicable.

+-----------------------------+----+----+------+------+------+------+
| **Budget Justification FY   | ** |    | **   | **   | **   | **   |
| 2008-2012**                 | Ye |    | Year | Year | Year | Year |
|                             | ar |    | 2**  | 3**  | 4**  | 5**  |
|                             | 1  |    |      |      |      |      |
|                             | ** |    |      |      |      |      |
+=============================+====+====+======+======+======+======+
|                             | *  | *  |      |      |      |      |
|                             | *C | *M |      |      |      |      |
|                             | HC | HC |      |      |      |      |
|                             | ** | ** |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| **REVENUE:** *Should be     |    |    |      |      |      |      |
| consistent with information |    |    |      |      |      |      |
| presented in FORM 3- Income |    |    |      |      |      |      |
| Analysis*                   |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| PROGRAM INCOME (fees,       | \$ | \$ | \$   | \$   | \$   | \$   |
| premiums, 3^rd^ party       |    |    |      |      |      |      |
| reimbursements and payments |    |    |      |      |      |      |
| generated from the          |    |    |      |      |      |      |
| projected delivery of       |    |    |      |      |      |      |
| services )                  |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| LOCAL & STATE FUNDS         | \$ | \$ | \$   | \$   | \$   | \$   |
| (including local,           |    |    |      |      |      |      |
| foundation and state        |    |    |      |      |      |      |
| grants)                     |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| OTHER SUPPORT (including    | \$ | \$ | \$   | \$   | \$   | \$   |
| contributions, fundraising) |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| FEDERAL 330 GRANT           | \$ | \$ | \$   | \$   | \$   | \$   |
+-----------------------------+----+----+------+------+------+------+
| OTHER FEDERAL FUNDING       | \$ | \$ | \$   | \$   | \$   | \$   |
| (Break out by funding       |    |    |      |      |      |      |
| source, e.g. HUD, CDC )     |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| **TOTAL REVENUE**           | ** | ** | **   | **   | **   | **   |
|                             | \$ | \$ | \$** | \$** | \$** | \$** |
|                             | ** | ** |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| **EXPENSES:** *Object Class |    |    |      |      |      |      |
| Totals should be consistent |    |    |      |      |      |      |
| with those presented in the |    |    |      |      |      |      |
| SF- 424A*                   |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| **[salary &                 |    |    |      |      |      |      |
| wages]{.underline}** *Use   |    |    |      |      |      |      |
| total salaries from         |    |    |      |      |      |      |
| categories listed in FORM   |    |    |      |      |      |      |
| 2--Staffing Profile.*       |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| *ADMINISTRATION (Total all  | \$ | \$ | \$   | \$   | \$   | \$   |
| Admin. salaries from Form   |    |    |      |      |      |      |
| 2)*                         |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| MEDICAL STAFF *(Total all   | \$ | \$ | \$   | \$   | \$   | \$   |
| Medical Salaries from Form  |    |    |      |      |      |      |
| 2)*                         |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| *DENTAL STAFF*              | \$ | \$ | \$   | \$   | \$   | \$   |
+-----------------------------+----+----+------+------+------+------+
| MENTAL HEALTH STAFF         | \$ | \$ | \$   | \$   | \$   | \$   |
+-----------------------------+----+----+------+------+------+------+
| ENABLING STAFF              |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| OTHER STAFF                 |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| **TOTAL: SALARY & WAGES     | ** | ** | **   | **   | **   | **   |
| (A)**                       | \$ | \$ | \$** | \$** | \$** | \$** |
|                             | ** | ** |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| **[Fringe                   | \$ | \$ | \$   | \$   | \$   | \$   |
| Benefits]{.underline}**     |    |    |      |      |      |      |
|                             | \$ | \$ | \$   | \$   | \$   | \$   |
| FICA                        |    |    |      |      |      |      |
|                             | \$ | \$ | \$   | \$   | \$   | \$   |
| Medical                     |    |    |      |      |      |      |
|                             | \$ | \$ | \$   | \$   | \$   | \$   |
| Retirement                  |    |    |      |      |      |      |
|                             | \$ | \$ | \$   | \$   | \$   | \$   |
| Dental                      |    |    |      |      |      |      |
|                             | \$ | \$ | \$   | \$   | \$   | \$   |
| Unemployment and Workers    |    |    |      |      |      |      |
| Compensation                |    |    |      |      |      |      |
|                             |    |    |      |      |      |      |
| Other                       |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| **TOTAL: FRINGE (B)**       | ** | ** | **   | **   | **   | **   |
|                             | \$ | \$ | \$** | \$** | \$** | \$** |
|                             | ** | ** |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| **TOTAL: PERSONNEL (A +     | ** | ** | **   | **   | **   | **   |
| B)**                        | \$ | \$ | \$** | \$** | \$** | \$** |
|                             | ** | ** |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+

#  {#section-12}

+-----------------------------+----+----+------+------+------+------+
| **Budget Justification FY   | ** |    | **   | **   | **   | **   |
| 2008-2012**                 | Ye |    | Year | Year | Year | Year |
|                             | ar |    | 2**  | 3**  | 4**  | 5**  |
|                             | 1  |    |      |      |      |      |
|                             | ** |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
|                             | *  | *  |      |      |      |      |
|                             | *C | *M |      |      |      |      |
|                             | HC | HC |      |      |      |      |
|                             | ** | ** |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #                           | \$ | \$ | \$   | \$   | \$   | \$   |
| ### [Equipment]{.underline} |    |    |      |      |      |      |
|                             |    |    |      |      |      |      |
| ####  {#section-13}         |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| Outreach and Enrollment (4  | \$ | \$ | \$   | \$   | \$   | \$   |
| laptop computers @          |    |    |      |      |      |      |
| \$X,000.00 ea)              |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| Clinical (2 blood pressure  | \$ | \$ | \$   | \$   | \$   | \$   |
| machines @ \$X,000 ea, 1    |    |    |      |      |      |      |
| autoclave @ \$X,000)        |    |    |      |      |      |      |
|                             |    |    |      |      |      |      |
| ####  {#section-14}         |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| **TOTAL: EQUIPMENT**        | ** | ** | **   | **   | **   | **   |
|                             | \$ | \$ | \$** | \$** | \$** | \$** |
|                             | ** | ** |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### [Supplies]{.underline} |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### Office and Prin        | \$ | \$ | \$   | \$   | \$   | \$   |
| ting Supplies (for 3 sites) |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### Dental Supplies (2,    | \$ | \$ | \$   | \$   | \$   | \$   |
| 000 encounters @ \$X.00 ea) |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### TOTAL: SUPPLIES        | ** | ** | **   | **   | **   | **   |
|                             | \$ | \$ | \$** | \$** | \$** | \$** |
|                             | ** | ** |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### [Travel]{.underline}   |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### Provider Tr            | \$ | \$ | \$   | \$   | \$   | \$   |
| aining (2 FTEs @ \$X.00 ea) |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### Outreach (50,          | \$ | \$ | \$   | \$   | \$   | \$   |
| 000 miles @ \$.XX per mile) |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### TOTAL: TRAVEL          | ** | ** | **   | **   | **   | **   |
|                             | \$ | \$ | \$** | \$** | \$** | \$** |
|                             | ** | ** |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### [Contractual]          |    |    |      |      |      |      |
| {.underline} Please describ |    |    |      |      |      |      |
| e with enough detail to jus |    |    |      |      |      |      |
| tify costs for both patient |    |    |      |      |      |      |
|  and non-patient contracts. |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### Outside Cont           | \$ | \$ | \$   | \$   | \$   | \$   |
| ract Pharmacies (3 pharmaci |    |    |      |      |      |      |
| es @ \$XXX.00 per contract) |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### O                      | \$ | \$ | \$   | \$   | \$   | \$   |
| B/GYN Contract with XX Prac |    |    |      |      |      |      |
| tice (\$XX.00 for deliverie |    |    |      |      |      |      |
| s for approx. 200 patients) |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### Ho                     | \$ | \$ | \$   | \$   | \$   | \$   |
| usekeeping Services (Contra |    |    |      |      |      |      |
| ct for services at 4 sites) |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### TOTAL: CONTRACTUAL     | ** | ** | **   | **   | **   | **   |
|                             | \$ | \$ | \$** | \$** | \$** | \$** |
|                             | ** | ** |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### [Other]{.underli       |    |    |      |      |      |      |
| ne} Please describe with en |    |    |      |      |      |      |
| ough detail to justify each |    |    |      |      |      |      |
|  item in the "other" catego |    |    |      |      |      |      |
| ry. Federal funding CANNOT  |    |    |      |      |      |      |
| support grant-writing fees. |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| ###                         | \$ | \$ | \$   | \$   | \$   | \$   |
| # Audit Service with X Firm |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### Dues, Memberships      | \$ | \$ | \$   | \$   | \$   | \$   |
+-----------------------------+----+----+------+------+------+------+
| #### Rent (\$X.00 per m     | \$ | \$ | \$   | \$   | \$   | \$   |
| onth, per site for 4 sites) |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### TOTAL: OTHER           | ** | ** | **   | **   | **   | **   |
|                             | \$ | \$ | \$** | \$** | \$** | \$** |
|                             | ** | ** |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+
| #### TOTAL EXPENSES         | ** | ** | **   | **   | **   | **   |
|                             | \$ | \$ | \$** | \$** | \$** | \$** |
| Should be consistent with   | ** | ** |      |      |      |      |
| the totals presented in     |    |    |      |      |      |      |
| Sections A and B of the     |    |    |      |      |      |      |
| SF-424A.                    |    |    |      |      |      |      |
+-----------------------------+----+----+------+------+------+------+

#  {#section-15}

#  {#section-16}

#  {#section-17}

#  {#section-18}

#  {#section-19}

#  {#section-20}

#  {#section-21}

# APPENDIX E

# INSTRUCTIONS FOR THE HEALTH CARE PLAN AND BUSINESS PLAN 

# DEVELOPING THE HEALTH CARE PLAN AND BUSINESS PLAN

Instructions for developing the Health Care and Business Plans are
below. Applicants should demonstrate that the timeline for both plans
are reasonable to assure that the applicant will be operational,
appropriate staff and providers will be available, and that the
applicant will deliver services at the same or comparable level as
presently being provided within 120 days of a grant award. A sample
format for the Health Care and Business Plans is also provided below.
**It is suggested that the combination of both the Health Care and
Business Plans Tables not exceed 30 pages in length.**

***Health Care Plan***

The Health Care Plan should be used to outline goals and objectives
related to the identified community health needs/issues and service
delivery activities discussed in the program narrative and should be
*specific to the proposed project supported by section 330 funding*.

The Health Care Plan presents the problem/needs statement,
goals/objectives, key action steps, expected outcomes, data evaluation
management, persons responsible and comments/progress.

Applicants currently receiving section 330 funding and applying to serve
their current service area should include relevant measures developed as
a result of their HRSA Office of Performance Review (OPR) site visit in
the Health Care Plan if they have received a site visit. The applicant
MAY BUT IS NOT REQUIRED TO provide a brief narrative describing any
additional information relevant to the Health Care Plan such as
challenges faced in meeting stated objectives and timelines. The
optional narrative should be included in the Response section of the
program narrative. **It is suggested that the Health Care Plan Table
should not exceed 15 pages in length.**

If special populations (e.g., migrant/seasonal agricultural workers,
residents of public housing, homeless persons) are included in the
target population, the Health Care Plan must describe how the special
access problems and the unique health care needs of these populations
are being met. Applicants are expected to address the following in their
Health Care Plan, as applicable:

-   Major health related goals and objectives for the patients in each
    of the life cycles.

-   Improving performance, quality, and outcomes, e.g., quality
    improvement plan activities, Healthy People 2010 Objectives, Health
    Disparities Collaboratives, Health Plan Employer Data and
    Information Set (HEDIS) measures, accreditation standards, Relative
    Value Units.

```{=html}
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```
-   Eliminating health disparities as appropriate for the target
    community/population, such as infant mortality, adult and pediatric
    immunizations, diabetes mellitus, obesity, cardiovascular disease,
    HIV infection, cancer prevention, asthma, and hypertension.

-   Relevant measures identified as a result of an OPR site visit (as
    applicable). Applicants will be expected to report their progress on
    the OPR measure(s) in subsequent non-competing continuation
    applications. Baseline data should be derived from currently
    established management information systems.

***Business Plan***

The Business Plan should be used to outline goals and objectives related
to the identified administrative, governance, finance, and management
information systems discussed in the program narrative and should be
*specific to the proposed project supported by section 330 funding*.

The Business Plan presents the problem/needs statement,
goals/objectives, key action steps, expected outcomes, data evaluation
management, persons responsible and comments/progress. Applicants
currently receiving section 330 funding and applying to serve their
current service area should include relevant measures developed as a
result of their HRSA Office of Performance Review (OPR) site visit in
the Business Plan if they have received a site visit.

The Business Plan should be consistent with applicable program
expectations and indicate how the goals and objectives of the
organization are tied into the overall operational business goals of the
organization and the community.

The applicant MAY BUT IS NOT REQUIRED TO provide a brief narrative
describing any additional information relevant to the Business Plan such
as challenges faced in meeting stated objectives and timelines. The
optional narrative should be included in the Resources/Capabilities
section of the program narrative. **It is suggested that** **the
Business Plan Table should not exceed 15 pages in length.**

The Business Plan should be formatted in the categories of:
Administrative, Governance, Fiscal, and Management Information Systems.
Applicants are expected to address the following issues, as applicable,
in the Business Plan:

-   Emergency preparedness and management.

-   Recruitment and retention of key management and staff, including
    clinical personnel.

-   Activities related to managed care.

-   Cost-savings activities such as joint purchasing or network
    development.

-   Continuous quality improvement relative to administrative/fiscal
    activities.

-   Plans for attaining and maintaining long-term viability (i.e.,
    future requirements for space, personnel, capital, etc.).

-   Financial, management and administrative implications to the
    organization.

-   Governance issues/changes necessary.

-   Any additional areas identified as a result of an OPR site visit (as
    applicable). Applicants will be expected to report their progress on
    the OPR measure(s) in subsequent non-competing continuation
    applications. Baseline data should be derived from currently
    established management information systems.

***Elements of the Health Care and Business Plan Table***

**Problem/Need Statements** are clearly and specifically defined
descriptions of major needs or problems, quantified where possible. For
example, such statements in the Health Care Plan may address:

1.  Needs of the overall health system, covering multiple programs and
    populations;

2.  Identification of disparities in health outcomes among populations
    served;

3.  Need for practice performance improvement in a targeted health
    disparity area;

4.  Problems of a specific program, service, or population; and

5.  Specific public health problems (e.g., high infant mortality; high
    prevalence of HIV disease; complications from diabetes; high
    prevalence of cocaine addiction).

**Column 1: Goals and Objectives**

**Goals** are relatively broad statements relating to significant needs
or problems identified in the service population; they provide a sense
of direction as how the grantee plans to address the need/problem.
Examples of a measurable HCP goal are: GOAL: *"To reduce the high infant
morbidity and mortality, the grantee plans to annually increase the
percentage of women entering prenatal care in the first trimester to
reach a target of 90% at the end of the project period" , or, "To reduce
the incidence of cancer among female residents over age 45 in the
service area by 50% at the end of the project period".* **Applicants are
expected to maintain goals throughout the entire approved project
period.**

**Objectives** are time framed and measurable statements of efforts to
be taken in moving toward the stated goal. Objectives should be timed to
be accomplished within the project period; shorter time frames such as
annual (Budget period) objectives are easier to measure and
modify/adjust each year based on the grantee's own experience. *For
example: A.1. At least 90% of female patients over age 45 should have a
Pap test annually, as appropriate. A.2. At least 90% of female patients
over age 45 should receive patient education regarding self breast exams
annually.* **Applicants are expected to report progress achieved on the
objectives in the subsequent budget period renewal application.**

Use an upper case letter (A., B., C.) for each goal and list
corresponding objectives by number (1., 2., 3.).

**Column 2:** **Key Action Step** - A specific step which will be taken
to achieve the stated objective. Use an upper case letter for goals, a
number for objectives, and a lower case letter assigned for each key
action step (i.e., A.1.a.).

**Column 3: Expected Outcomes -** These concise statements provide the
projected level of completion of each objective within the budget
period. *For example: A.1. 80% of female patients over age 45 will have
an appropriate Pap test by 12/31/07. A.2. 85% of female patients over
age 45 will receive patient education regarding self breast exams by end
of 12/31/07.*

**Column 4: Data, Evaluation, & Measurement** - The source of data,
method of evaluation/analysis and measurement used to evaluate progress
towards an objective. Measures should be based on valid and reliable
data derived from currently established management information systems.
The measure should also define the numerator and denominator used by the
grantee to determine the level of progress of each objective. (e.g.,
Numerator: Total number of women staring prenatal care by end of 1^st^
trimester during the reporting period/Denominator: Total number of women
beginning prenatal care during the reporting year.

**Column 5: Person/Area Responsible** -- Indicate the person or area of
the operation responsible for the tracking, evaluation and completion of
the objectives and key action steps.

**Column 6: Comments** - Supplementary information for related entries
in the plan, including a brief summary statement on the he measurable
progress and/or current status towards completion of each objective.

###### Sample Format for the Health Care Plan & Business Plan Presentations

This sample format is provided as a broad outline for the Health Care
Plan and Business Plan presentations. Additional information may be
provided to fully describe your proposal:

+---------+------------+-----------+----------+----------+------------+
| Probl   |            |           |          |          |            |
| em/Need |            |           |          |          |            |
| Sta     |            |           |          |          |            |
| tement: |            |           |          |          |            |
| D       |            |           |          |          |            |
| iabetes |            |           |          |          |            |
| is a    |            |           |          |          |            |
| common  |            |           |          |          |            |
| di      |            |           |          |          |            |
| agnosis |            |           |          |          |            |
| among   |            |           |          |          |            |
| p       |            |           |          |          |            |
| atients |            |           |          |          |            |
| of CHC, |            |           |          |          |            |
| Inc.    |            |           |          |          |            |
| CHC,    |            |           |          |          |            |
| Inc.    |            |           |          |          |            |
| aims to |            |           |          |          |            |
| improve |            |           |          |          |            |
| care    |            |           |          |          |            |
| and     |            |           |          |          |            |
| quality |            |           |          |          |            |
| of life |            |           |          |          |            |
| for its |            |           |          |          |            |
| clients |            |           |          |          |            |
| with    |            |           |          |          |            |
| d       |            |           |          |          |            |
| iabetes |            |           |          |          |            |
| by      |            |           |          |          |            |
| rede    |            |           |          |          |            |
| signing |            |           |          |          |            |
| the     |            |           |          |          |            |
| d       |            |           |          |          |            |
| elivery |            |           |          |          |            |
| of      |            |           |          |          |            |
| health  |            |           |          |          |            |
| care    |            |           |          |          |            |
| se      |            |           |          |          |            |
| rvices. |            |           |          |          |            |
+---------+------------+-----------+----------+----------+------------+
| Go      | Key Action | Expected  | Data,    | Per      | Comments   |
| als/Obj | Steps      | Outcome   | Ev       | son/Area |            |
| ectives |            |           | aluation | Res      |            |
|         |            |           | &        | ponsible |            |
|         |            |           | Mea      |          |            |
|         |            |           | surement |          |            |
+---------+------------+-----------+----------+----------+------------+
| A. To   | A.1.(a)    | A.1.(a)   | A.1(a)   | A.1.(a)  | A.1.(a)    |
| improve | Track      | By 5/06,  | Medical  | Nursing  | Healthy    |
| the     | patients   | 90% of    | Records  | Staff    | People     |
| health  | to insure  | patients  |          |          | 2010 Goals |
| status  | they have  | have had  | A.1(b)   | A.1.(b)  | and Obj    |
| of      | annual     | a retinal | Data,    | Per      | (5-1       |
| p       | retinal    | eye exam  | Eval &   | son/Area | through    |
| atients | eye exams  | in the    | Meas     |          | 5-17).     |
| with    | and foot   | last 12   |          | A.1.(c)  |            |
| d       | exams.     | mts       | A.1.(c)  | Per      | A.1.(b)    |
| iabetes | Refer as   |           | Data,    | son/Area | Comments   |
|         | needed     | A.1.(b)   | Eval &   |          |            |
| A.1. At |            | Expected  | Meas     | A.2.(a)  | A.1.(c)    |
| least   | A.1 (b)    | Outcome   |          | Per      | Comments   |
| 90% of  | Action     |           | A.2.(a)  | son/Area |            |
| p       | step 2 for | A.1.(c)   | Data,    |          | A.2.(a)    |
| atients | Objective  | Expected  | Eval &   | A.2.(b)  | Comments   |
| will    | 1          | Outcome   | Meas     | Per      |            |
| have    |            |           |          | son/Area | A.2.(b)    |
| had a   | A.1.(c)    | A.2.(a)   | A.2.(b)  |          | Comments   |
| retinal | Action     | Expected  | Data,    |          |            |
| eye     | step 3 for | Outcome   | Eval     |          |            |
| exam in | Objective  |           | &Meas    |          |            |
| the     | 1          | A.2.(b)   |          |          |            |
| last 12 |            | Expected  |          |          |            |
| months  | A.2.(a)    | Outcome   |          |          |            |
| by 5/06 | Action     |           |          |          |            |
|         | step 1 for |           |          |          |            |
| A.2.    | Objective  |           |          |          |            |
| Ob      | 2          |           |          |          |            |
| jective |            |           |          |          |            |
| (2)     | A.2 (b)    |           |          |          |            |
|         | Action     |           |          |          |            |
|         | step 2 for |           |          |          |            |
|         | Objective  |           |          |          |            |
|         | 2          |           |          |          |            |
+---------+------------+-----------+----------+----------+------------+
| Probl   |            |           |          |          |            |
| em/Need |            |           |          |          |            |
| Sta     |            |           |          |          |            |
| tement: |            |           |          |          |            |
| Re      |            |           |          |          |            |
| taining |            |           |          |          |            |
| a       |            |           |          |          |            |
| well-qu |            |           |          |          |            |
| alified |            |           |          |          |            |
| wo      |            |           |          |          |            |
| rkforce |            |           |          |          |            |
| is      |            |           |          |          |            |
| c       |            |           |          |          |            |
| ritical |            |           |          |          |            |
| to the  |            |           |          |          |            |
| success |            |           |          |          |            |
| of any  |            |           |          |          |            |
| organi  |            |           |          |          |            |
| zation. |            |           |          |          |            |
+---------+------------+-----------+----------+----------+------------+
| B.      | B.1.(a)    | B.1.(a)   | B.1.(a)  | B.1.(a)  | B.1.(a)    |
| M       | Develop    | All staff | P        | Human    | Comments   |
| aintain | annual     | will have | ersonnel | R        |            |
| well-qu | p          | a         | records  | esources | B.1.(b)    |
| alified | erformance | pe        | and      |          | Comments   |
| staff   | evaluation | rformance | employee | B.1.(b)  |            |
| for     | and        | e         | sati     | Per      | B.2.(a)    |
| health  | employee   | valuation | sfaction | son/Area | Comments   |
| center. | sa         | and       | survey   |          |            |
|         | tisfaction | completed |          | B.2.(a)  | B.2.(b)    |
| B.1.    | survey.    | sat       | B.1.(b)  | Per      | Comments   |
| Im      |            | isfaction | Data,    | son/Area |            |
| plement | B.1 (b)    | survey by | Ev       |          |            |
| an      | Action     | end of    | aluation | B.2.(b)  |            |
| annual  | step 2 for | year.     | &        | Per      |            |
| perf    | Objective  |           | Mea      | son/Area |            |
| ormance | 1          | B.1.(b)   | surement |          |            |
| eva     |            | Expected  |          |          |            |
| luation | B.2.(a)    | Outcome   | B.2.(a)  |          |            |
| and     | Action     |           | Data,    |          |            |
| e       | step 1 for | B.2.(a)   | Ev       |          |            |
| mployee | Objective  | Expected  | aluation |          |            |
| satis   | 2          | Outcome   | &        |          |            |
| faction |            |           | Mea      |          |            |
| p       | B.2 (b)    | B.2.(b)   | surement |          |            |
| rogram. | Action     | Expected  |          |          |            |
|         | step 2 for | Outcome   | B.2.(b)  |          |            |
| B.2.    | Objective  |           | Data,    |          |            |
| Ob      | 2          |           | Ev       |          |            |
| jective |            |           | aluation |          |            |
| (2)     |            |           | &        |          |            |
|         |            |           | Mea      |          |            |
| B.3.    |            |           | surement |          |            |
| Ob      |            |           |          |          |            |
| jective |            |           |          |          |            |
| (3)     |            |           |          |          |            |
+---------+------------+-----------+----------+----------+------------+
| C. Goal | C.1.(a)    | C.1.(a)   | C.1.(a)  | C.1.(a)  | C.1.(a)    |
|         | Action     | Expected  | Data,    | Per      | Comments   |
| C.1.    | step 1 for | Outcome   | Ev       | son/Area |            |
| Ob      | Objective  |           | aluation |          | C.1.(b)    |
| jective | 2          | C.1.(b)   | &        | C.1.(b)  | Comments   |
| (1)     |            | Expected  | Mea      | Per      |            |
|         | C.1 (b)    | Outcome   | surement | son/Area |            |
|         | Action     |           |          |          |            |
|         | step 2 for |           | C.1.(b)  |          |            |
|         | Objective  |           | Data,    |          |            |
|         | 2          |           | Ev       |          |            |
|         |            |           | aluation |          |            |
|         |            |           | &        |          |            |
|         |            |           | Mea      |          |            |
|         |            |           | surement |          |            |
+---------+------------+-----------+----------+----------+------------+

#  {#section-22}

#  {#section-23}

# APPENDIX F:

# FY 2008 SERVICE AREAS 

ORGANIZATIONS INTERESTED IN ANY OF THESE COMPETITIVE OPPORTUNITIES

ARE ENCOURAGED TO CONTACT THE LISTED PROGRAM OFFICIALS

FOR MORE INFORMATION.

+-----------------+---------------+-------+------------+-------------+
| **Project       | **Service     | **St  | **Target** | **HRSA      |
| Period Start    | Area City**   | ate** |            | A           |
| Date**          |               |       | **Popul    | nnouncement |
|                 |               |       | ation(s)** | Number**    |
|                 |               |       |            |             |
|                 |               |       | **Served** |             |
+-----------------+---------------+-------+------------+-------------+
| April 1, 2008   | Corbin        | KY    | CH         | HRSA-08-112 |
+-----------------+---------------+-------+------------+-------------+
| April 1, 2008   | Tylertown     | MS    | CH         | HRSA-08-112 |
+-----------------+---------------+-------+------------+-------------+
| June 1, 2008    | Manson        | NC    | CH         | HRSA 08-113 |
+-----------------+---------------+-------+------------+-------------+

####### Organizations interested in this competitive opportunity are encouraged to contact HRSA for additional information. Listed below are the names of agency contacts for each service area.

-   Corbin, KY and Tylertown, MS: Kimberly Range, Branch Chief,
    Southeast Branch, Eastern Division; 301-594-4341

-   Manson, NC: Margaret Davis, Branch Chief, East Atlantic Branch,
    Eastern Division; 301-594-0291

#######   {#section-24}

#######   {#section-25}

#######  {#section-26}

#######  {#section-27}

#######  {#section-28}

#######  {#section-29}

#######  {#section-30}

# APPENDIX G:

# PRIMARY CARE ASSOCIATION,

# PRIMARY CARE OFFICE AND

# NATIONAL ORGANIZATION CONTACTS

***PRIMARY CARE ASSOCIATION, PRIMARY CARE OFFICE AND NATIONAL
ORGANIZATION CONTACTS***

##### I. PRIMARY CARE ASSOCIATIONS

**ALABAMA**

Al Fox, Executive Director

AL Primary Health Care Association

6008 E. Shirley Lane, Suite A

Montgomery, Alabama 36117

Phone: 334/271-7068; Fax: 334/271-7069

Email: [afox@alphca.com](mailto:AFOX@ALPHCA.COM)

<http://www.adph.org/aphca>

# ALASKA 

Marilyn Kasmar, RNC, MBA

Executive Director

Alaska Primary Care Association, Inc.

903 W. Northern Lights Blvd., Suite 105

Anchorage, Alaska 99503

Phone: 907/929-2722; Fax: 907/929-2734

Email: [marilyn@alaskapca.org](mailto:MARILYN@ALASKAPCA.ORG)

<http://www.alaskapca.org/>

### ARIZONA

Joseph S. Coatsworth

Chief Executive Officer

Arizona Association of Community Health Center, Inc.

320 E. McDowell Street, Suite 225

Phoenix, Arizona 85004

Phone: 602/253-0090; Fax: 602/252-3620

Email: [coatsworth@aachc.org](mailto:COATSWORTH@AACHC.ORG)

<http://www.aachc.org/>

### ARKANSAS

Sip B. Mouden, Executive Director

Community Health Centers/Arkansas, Inc.

420-A West 4th Street

North Little Rock, Arkansas 72114

Phone: 501/374-8225; Fax: 501/374-9734

Email: <sbmouden@CHC-AR.ORG>

<http://www.chc-ar.org/>

### CALIFORNIA

Carmela Castellano-Garcia, Esq.

Chief Executive Officer

California Primary Care Association

1215 K Street, Suite 700

Sacramento, California 95814

Phone: 916/440-8170; Fax: 916/440-8172

Email: [ccastellano@cpca.org](mailto:CCASTELLANO@CPCA.ORG)

<http://www.cpca.org/>

### COLORADO

Annette Kowall, Chief Executive Officer

CO Community Health Network

600 Grant Street, Suite 800

Denver, Colorado 80203

Phone: 303/861-5165, ext. 228

Fax: 303/861-5315

Email: [annette@cchn.org](mailto:ANNETTE@CCHN.ORG)

<http://www.cchn.org/>

### CO - CHAMPS

Julie Hulstein, Executive Director

Community Health Association Mountain\
/Plains States (CHAMPS)

600 Grant Street, Suite 800

Phone: 303/861-5165, ext. 226

Denver, Colorado 80203

Fax: 303/861-5315

Email: [julie@champsonline.org](mailto:JULIE@CHAMPSONLINE.ORG)

<http://www.champsonline.org/chmp.htm>

**CONNECTICUT**

Evelyn A.Barnum, J.D.

Executive Director

Connecticut Primary Care Association

90 Brainard Road, Suite 101

Hartford, Connecticut 06114-1685

Phone: 860/727-0004; Fax: 860/727-8550

Email: [ebarnum@ctpca.org](mailto:EBARNUM@CTPCA.ORG)

<http://www.ctpca.org/>

### DISTRICT OF COLUMBIA

Sharon Baskerville, Executive Director

District of Columbia Primary Care Association\
1411 K Street, NW, Suite 400

Washington, D.C. 20005

Phone: 202/638-0252; Fax: 202/638-4557

Email: [sbaskerville@dcpca.org](mailto:SBASKERVILLE@DCPCA.ORG)

<http://www.dcpca.org/>

### FLORIDA

Andrew Behrman, Chief Executive Officer

Florida Association of Community Health Ctrs

433 N. Magnolia Drive

Tallahassee, Florida 32308-5083

Phone: 850/942-1822; Fax: 850/942-9902

Email: [abehrman@fachc.org](mailto:ABEHRMAN@FACHC.ORG)

<http://www.fachc.org/>

### GEORGIA

Duane Kavka, Executive Director

Georgia Association for Primary Health Care, Inc.

44 Broad Street, NW, Suite 410

Atlanta, Georgia 30303

Phone: 404/659-2861; Fax: 404/659-2801

Email: [dkavka@gaphc.org](mailto:DKAVKA@GAPHC.ORG)

<http://www.gaphc.org/>

### HAWAII

Beth Giesting, Executive Director

Hawaii Primary Care Association

345 Queens Street, Suite 601

Honolulu, Hawaii 96813-4718

Phone: 808/536-8442; Fax: 808/524-0347

Email: [bgiesting@hawaiipca.net](mailto:BGIESTING@HAWAIIPCA.NET)

<http://www.hawaiipca.net/>

###  IDAHO

Kathy Coumerilh

*Interim Executive Director*

Idaho Primary Care Association

1276 W. River Street, Suite 202

Boise, Idaho 83702

Phone: 208/345-2335; Fax: 208/386-9945

Email:

<kathyc@idahopca.org>

<http://www.idahopca.org/>

### ILLINOIS

Bruce A. Johnson, Chief Executive Officer

Illinois Primary Health Care Association

225 S. College, Suite 200

Springfield, Illinois 62704

Phone: 217/541-7305; Fax: 217/-541-7306

Email: [bjohnson@iphca.org](mailto:BJOHNSON@IPHCA.ORG)

<http://www.iphca.org/>

**INDIANA**

Lisa Winternheimer

Indiana Public Health Care Association, Inc.

1006 E. Washington Street, Suite 200

Indianapolis, Indiana 46202

Phone: 317/630-0845; Fax: 317/630-0849

Email: <lwinternheimer@ori.net>)

<http://www.indianapca.org/>

**IOWA-NEBRASKA**

Theodore J. Boesen, Jr.

Executive Director

Iowa-Nebraska, PCA

601 E. Locust Street, Suite 102

Des Moines, Iowa 50309

Phone: 515/244-9610; Fax: 515/243-3566

Email: <ianepcatboesen@aol.com>

<http://www.ianepca.com/>

### KANSAS

Karla Finnell, JD, MPH\
Executive Director

Kansas Association the Medically Underserved

112 SW 6th Street, Suite B

Topeka, Kansas 66604

Phone: 785/233-8483; Fax: 785/233-8403

Email: <kfinnell@kspca.org>

[http://www.kspca.org](http://www.kspca.org/)

### KENTUCKY

Joseph E. Smith, Executive Director

Kentucky Primary Care Association

226 W. Main Street, 2^nd^ Floor

Frankfort, Kentucky 40602

Phone: 502/227-4379; Fax: 502/223-7654

Email: [jesmith@fewpb.net](mailto:JESMITH@FEWPB.NET)

http://[www.kypca.net](http://www.kypca.net/).

###  LOUISIANA Rhonda L. Litt, Executive Director Louisiana Primary Care Association, Inc. 4550 North Blvd, Suite 120 Baton Rouge, Louisiana 70806-0966 Phone: 225/324-0638; Fax: 225/927-7688 Email: [**rhonda@lpca.net**](mailto:RHONDA@LPCA.NET) [**http://www.lpca.net**](http://www.lpca.net/) 

#### MAINE Kevin Lewis, Executive Director Maine Primary Care Association 73 Winthrop Street Augusta, Maine 04330-5505 Phone: 207/621-0677; Fax: 207/621-0577 Email: [**kalewis@mepca.org**](mailto:KALEWIS@MEPCA.ORG) [**http://www.mepca.org/mepca/Home.asp**](http://www.mepca.org/mepca/Home.asp)

### MARYLAND/DELAWARE

Miguel Mcinnis, MPH

Chief Executive Officer

Mid-Atlantic Association of Community Health Centers

4483-B Forbes Boulevard

Forbes Center Building II

Lanham, Maryland 20706

Phone: 301/577-0097; Fax: 301/577-4789

Email: [miguel.mcinnis@machc.com](mailto:MIGUEL.MCINNIS@MACHC.COM)

[http://www.machc.com](http://www.machc.com/)

###  MASSACHUSETTS

Jim W. Hunt Jr., MUA, CAE,

President & Chief Executive Officer

Massachusetts League of CHCs

100 Boylston Street, Suite 700

Boston, Massachusetts 02116

Phone: 617/426-2225; Fax: 617/426-0097

Email: [jhunt@massleague.org](mailto:JHUNT@MASSLEAGUE.ORG)\
<http://www.massleague.org/>

#### MICHIGAN

Kim Sibilsky, Executive Director

Michigan Primary Care Association

7215 Westshire Drive

Lansing, MI 48917

Phone: 517/381-8000

Fax: 517/381-8008

Email: [ksibilsky@mpca.net](mailto:KSIBILSKY@MPCA.NET)

[http://www.mpca.net](http://www.mpca.net/)

### MINNESOTA

Rhonda Degelau, Executive Director

Minnesota Association of Community Health Centers

1113 E. Franklin Ave.

Suite 211

Minneapolis, Minnesota 55404

Phone: 612/253-4715; Fax: 612/872-7849

Email: [rhonda.degelau@mnpca.org](mailto:RHONDA.DEGELAU@MNPCA.ORG)

[http://www.mnachc.org](http://www.mnachc.org/)

**MISSISSIPPI**

Robert M. Pugh, MPH

Executive Director

Mississippi Primary Health Care Association

6400 Lakeover Road, Suite A

Jackson, Mississippi 39213

Phone: 601/981-1817; Fax: 601/981-1217

Email: [rmpugh@mphca.com](mailto:RMPUGH@MPHCA.COM)

<http://www.mphca.com/>

### MISSOURI

Joseph Pierle, MPA

Executive Director

Missouri Primary Care Association

3325 Emerald Lane

Jefferson City, Missouri 65109

Phone: 573/636-4222; Fax: 573/636-4585

Email: [jpierle@mo-pca.org](mailto:JPIERLE@MO-PCA.ORG)

[http://www.mo-pca.org](http://www.mo-pca.org/)

### MONTANA

Alan Strange, Ph.D.

Director

Montana Primary Care Association

900 North Montana Ave., Suite 3B

Helena, Montana 59601

Phone: 406/442-2750; Fax: 406/449-2460

Email: [astrange@mtpca.org](mailto:ASTRANGE@MTPCA.ORG)

<http://www.mtpca.org/>

### NEVADA

Patricia Durbin

Executive Director

Great Basin Primary Care Association

515 W. 4^th^ Street

Carson City, Nevada 89703

Phone: 775/887-0417, ext. 101

Fax: 775/887-3562

Email: PDurbin@gbpca.org

http://[www.gbpca.org](http://www.gbpca.org/)

### NEW HAMPSHIRE/VERMONT

Tess Stack Kuenning, Executive Director

New Hampshire Bi-State PCA

3 South Street

Concord, New Hampshire 03301

Phone: 603/228-2830; Fax: 603/228-2464

Email: [tkuenning@bistatepca.org](mailto:TKUENNING@BISTATEPCA.ORG)

<http://www.bistatepca.org/>

### NEW JERSEY

Katherine Grant-Davis, Executive Director

New Jersey Primary Care Association

14 Washington Road, Suite 211

Princeton Junction, New Jersey 08550-1030

Phone: 609/275-8886; Fax: 609/936-7247

Email: [njpca2@aol.com](mailto:NJPCA2@AOL.COM)

[http://www.njpca.org](http://www.njpca.org/)

###  NEW MEXICO

David Roddy, Executive Director\
New Mexico Primary Care Association\
4545 McLeod, N.E., Suite D

Albuquerque, New Mexico 87109

Phone: 505/880-8882; Fax: 505/880-8885

Email: [droddy@nmpca.org](mailto:DRODDY@NMPCA.ORG)

<http://www.nmpca.org/>

### NEW YORK

Elizabeth Swain, Executive Director\
Community Health Center Association\
of New York State, Inc.

254 W. 31^st^ Street, 9th\
New York, NY 10001\
Phone: 518/761-0300, ext. 111\
Fax: 212/279-3851\
Email: <eswain@chcanys.org>\
<http://www.chcanys.org/>

### NORTH CAROLINA

Sonya J. Bruton, MPA

Executive Director

North Carolina PHCA

2500 Gateway Center, Suite 100

Morrisville, North Carolina 27560

Phone: 919/297-0012; Fax: 919/469-1263

Email: <brutons@ncchca.org>

<http://www.ncphca.org/>

### NORTH DAKOTA

Karen E. Larsen, Deputy Director

Community HealthCare Association of the Dakotas

1003 East Interstate Avenue, Suite 6

Bismarck, ND 58503

Phone: 701/221-9824

Fax: 701/221-0615 fax

Email: <karen@communityhealthcare.net>

<http://www.communityhealthcare.net/>

### OHIO

Shawn Frick, Executive Director

Ohio Association of Community Health Centers

4150 Indianola Avenue

Columbus, Ohio 43214-3214

Phone: 614/884-3101; Fax: 614/884-3108

Email: <sfrick@ohiochc.org>

<http://www.ohiochc.org/>

### OKLAHOMA

Greta Shepherd-Stewart, MPH

Executive Director

Oklahoma Primary Care Association

4300 N. Lincoln Blvd, Suite 203

Oklahoma City, Oklahoma 73105-5106

Phone: 405/424-2282, Fax: 405/242-1111

Email: [gshepherd@okpca.org](mailto:GSHEPHERD@OKPCA.ORG)

<http://www.okpca.org/>

###  OREGON Craig Hostetler, MHA

Executive Director

Oregon Primary Care Association

110 SW Yamhill Street, Suite 3000

Portland, Oregon 97204

Phone: 503/228-8852; Fax: 503/228-9887

Email: [chostetler@northwest.com](mailto:CHOSTETLER@NORTHWEST.COM)

Email: <chostetler@orpca.org>

http://[www.orpca.org](http://www.orpca.org/)

**PACIFIC BASIN**

Clifford Chang, Executive Director

Pacific Islands Primary Care Association

345 Queen Street, Suite 601

Honolulu HI 96813-4715

Tel: 808-536-8442 ext121\
Fax: 808-524-0347\
email: <cchang@pacificislandspca.org>

<pacificislandspca@yahoo.com>

### PENNSYLVANIA

Henry Fiumelli, Executive Director

Pennsylvania Forum for Public Health Center

1035 Mumma Road, Suite 1

Wormleysburg, Pennsylvania 17043-1147

Phone: 717/761-6443; Fax: 717/761-8730

Email: [henry@paforum.com](mailto:HENRY@PAFORUM.COM)

<http://www.paforum.com/>

### PUERTO RICO Alicia T. Suárez, M.A. Exécutive Director Asociacion de Salud Primaria de Puerto Rico, Inc.

201 De Diego Avenue, Suite 158

Plaza San Francisco

San Juan, PR 00927

Telephone: (787) 758-3411

Fax: (787) 758-1736

E-mail:acsppr@coqui.net

### RHODE ISLAND

Kerrie Jones Clark, Executive Director

Rhode Island Health Center Association

235 Promenade Street, Suite 104

Providence, Rhode Island 02908

Phone: 401/274-1771; Fax: 401/-274-1789

Email: [kclark@rihca.org](mailto:KCLARK@RIHCA.ORG)

[http://www.rihca.org](http://www.rihca.org/)

###  {#section-31}

###  SOUTH CAROLINA

Lathran Woodard, Executive Director

South Carolina PHCA

2211 Alpine Road Extension

Columbia, South Carolina 29223

Phone: 803/788-2778; Fax: 803/788-8233

Email: [lathran@scphca.org](mailto:LATHRAN@SCPHCA.ORG)

<http://www.scphca.org/>

### SOUTH DAKOTA

Scot Graff, MPA

Chief Executive Officer

Community Health Care Assn of the Dakotas

1400 W. 22^nd^ Street

Sioux Falls, South Dakota 57105-1570

Phone: 605/357-1515; Fax: 605/357-1510

Email: [sgraff@usd.edu](mailto:SGRAFF@USD.EDU)

<http://www.communityhealthcare.net/>

### TENNESSEE

Kathy Wood-Dobbins, Executive Director

Tennessee Primary Care Association

416 Wilson Pike Circle

Brentwood, Tennessee 37027-5203

Phone: 615/329-3836, ext.14

Fax: 615/329-3823

Email: [kathy@tnpca.org](mailto:KATHY@TNPCA.ORG)

<http://www.tnpca.org/>

**TEXAS**

Jose E. Camacho, Executive Director

Texas Association of Community Health Centers, Inc.

5900 Southwest Parkway, Building 3

Austin, Texas 78735

Phone: 512/329-5959; Fax: 512/329-9189

Email: [jcamacho@tachc.org](mailto:JCAMACHO@TACHC.ORG)

<http://www.tachc.org/>

##### UTAH

Bette Vierra, Executive Director

Association of Community Health Centers

860 East 4500 South, Suite 206

Salt Lake City, Utah 84107

Phone: 801/924-2846; Fax: 801/924-5563

Email: [bettevierra@auch.org](mailto:BETTEVIERRA@AUCH.ORG)

<http://www.auch.org/>

### VERMONT/ NEW HAMPSHIRE

Tess Stack Kuenning, Executive Director

Vermont Bi-State

61 Elm Street

Montpellier, Vermont 05602-2818

Phone: 802/229-0002; Fax: 802/223-2336

Email: [tkuenning@bistatepca.org](mailto:TKUENNING@BISTATEPCA.ORG)

<http://www.bistatepca.org/>

###  VIRGINIA

Neal Graham, Chief Executive Officer

Virginia Primary Care Association, Inc.

6802 Paragon Place, Suite 625

Richmond, Virginia 23230\
Phone: 804/378-8801, ext. 17

Fax: 804/379-6593

Email: [ngraham@vpca.com](mailto:NGRAHAM@VPCA.COM)

<http://www.vpca.com/>

**WASHINGTON**

Ben Flores, Chief Executive Officer

Washington Association of CMHC

2120 State Avenue, N.E., Suite 220

Olympia, Washington 98506

Phone: 360/786-9722; Fax: 360/786-9723\
Email: <bflores@wacmhc.org>

<http://www.wacmhc.org/>

**WA-NORTH WEST REGIONAL**

Bruce Gray, MPA

Chief Executive Officer

Northwest Regional Primary Care Association

6512 23^rd^ Avenue, NW, Suite 305

Seattle, Washington 98117

Phone: 206/783-3004; Fax: 206/783-4311

Email: <bgray@nwrpca.org>

<http://www.nwrpca.org/>

### WEST VIRGINIA Phil Schenk, Executive Director West Virginia Primary Care Association, Inc. 1219 Virginia Street, East Charleston, West Virginia 25301 Phone: 304/346-0032; Fax: 304/346-0033 Email: <phil@wvpca.org>

http://[www.wvpca.org](http://www.wvpca.org/)

### WISCONSIN

Stephanie Harrison, 

Wisconsin Primary Health Care Association

4600 American Parkway, Suite 204

Madison, Wisconsin 53718

Phone: 608/277-7477, ext 226;

Fax: 608/-277-7474

Email: <sharrison@wphca.org>

<http://www.wphca.org/>

**\
WYOMING**

Pat Monahan,

Wyoming Primary Care Association

Post Office Box 113

Cheyenne, Wyoming 82003

Phone: 307/632-5743; Fax: 307/638-6103

Email: [wypca@wypca.org](mailto:WYPCA@WYPCA.ORG)

<http://www.wypca.org/>

**II. PRIMARY CARE OFFICES**

**[Alabama]{.underline}**

Charles Lail,

Primary Care & Rural Health State of Alabama

Alabama Department of Health

201 Monroe Street, P.O. Box 303017

Montgomery, AL 36130-3017

Phone: (334) 206-5396

Fax: (334) 206-5434

Email: <clail@adph.state.al.us>

[www.adph.org/opcrh](http://www.adph.org/opcrh)

**[Alaska]{.underline}**

Mark Millard

Health Planning and Systems Development

State of Alaska

Department of Health and Social Services

Office of the Commissioner

P.O. Box 110601

Juneau, AK 99811-0601

Phone: (907) 465-8534

Fax: (907) 465-6861

Email: <mark_millard@health.state.ak.us>

<http://www.hss.state.ak.us/commissioner/>

**[Arizona]{.underline}**

Patricia Tarango

Office of Health Systems Development

Arizona Department of Health Services

1740 West Adams, Room 410

Phoenix, AZ 85007

Phone: (602) 542-1219

Fax: (602) 542-2011

Email: <tarangp@azdhs.gov>

**[Arkansas]{.underline}**

Bill Rodgers

Office of Rural Health and Primary Care

Arkansas Department of Health and Human Services

P.O. Box 1437 -- H22

Little Rock, AR 72203-1437

Phone: (501) 280-4563

Fax: (501) 280-4706

Email: <William.rodgers@arkansas.gov>

**[California]{.underline}**

Angela L. Minniefield

Healthcare Workforce & Community Development Division

Office of Statewide Health Planning & Development

1600 9^th^ Street, Room 440

Sacramento, CA 95814

Phone: (916) 653-0733

Fax: (916) 654-3138

Email: <aminnief@oshpd.ca.gov>

[www.oshpd.ca.gov](http://www.oshpd.ca.gov/)

**[Colorado]{.underline}**

Kitty Stevens

Primary Care Office

Colorado Department of Public Health & Environment

4300 Cherry Creek Drive, South

Denver, CO 80246-1530

Phone: (303) 692-2582

Fax: (303) 758-3448

Email: <kitty.stevens@state.co.us->

[www.cdphe.state.co.us/pp/primarycare/index.html](http://www.cdphe.state.co.us/pp/primarycare/index.html)

**[Connecticut]{.underline}**

Felicia Epps

Connecticut Department of Public Health

410 Capitol Avenue, Mail stop #11 PSI

Hartford, CT 06134-0308

Phone: (860) 509-8074

Fax: (860) 509-8403

Email: <Felicia.epps@po.state.ct.us>

**[Delaware]{.underline}**

Kathy Collison

Division of Public Health

Delaware Department of Health & Social Services

655 Bay Road, Suite 206

Dover, DE 19901

Phone: (302) 741-2960

Fax: (302) 741-2970

Email: <Katherine.collison@state.de.us>

**[District of Columbia]{.underline}**

David Rose

District of Columbia Department of Health

Primary Health Services

825 N. Capital Street, NE, Room 4160

Washington, DC 20002

Phone: (202) 442-8984

Fax: (202) 535-1039

Email: <david.rose@dc.gov>

<http://doh.dc.gov/doh/site/default.asp>

**[Florida]{.underline}**

Gail Underwood

Division of Health Access and Tobacco

Office of Health Professional Recruitment

Florida Department of Health

4052 Bald Cypress Way, Bin C-15

Tallahassee, FL 32399-1735

Phone: 1-800-342-8660 x2709

Fax: (850) 922-6296

Email: <gail_underwood@doh.state.fl.us>

[www.doh.state.fl.us/workforce/recruit1/index.html](http://www.doh.state.fl.us/workforce/recruit1/index.html)

**[Georgia]{.underline}**

Charles Owens

State Office of Rural Health

Georgia Department of Community Health

502 South 7^th^ Street

Cordele, GA 31015-4214

Phone: (229) 401-3090

Fax: (229) 401-3077

Email: <cowens@dch.state.ga.us>

**[Hawaii]{.underline}**

Valerie Yin

State of Hawaii, Department of Health

Office of Planning Policy & Program Development

1250 Punchbowl Street, Room 340

Honolulu, Hawaii 96813

Phone: (808) 586-4187

Fax: (808) 586-4193

Email: <valerie.yin@doh.hawaii.gov>

**[Idaho]{.underline}**

Laura Rowen

State Office of Rural Health & Primary Care

Idaho Department of Health & Welfare

450 West State Street, 4^th^ Floor

Boise, ID 83720-0036

Phone: (208) 334-5993

Fax: (208) 332-7262

Email: <rowenl@idhw.state.id.us>

<http://www.healthandwelfare.idaho.gov/site/3459/default.aspx>

**[Illinois]{.underline}**

Marcia Franklin

Center for Rural Health

Illinois Department of Public Health

535 West Jefferson Street

Springfield, IL 62761

Phone: (217) 782-1624

Fax: (217) 782-2547

Email: <marcia.franklin@illinois.gov>

[www.idph.state.il.us](http://www.idph.state.il.us/)

**[Indiana]{.underline}**

Patrick Durkin

Indiana State Department of Health

2 North Meridian Street, Suite 8-B

Indianapolis, IN 46204-3006

Phone: (317) 233-7846

Fax: (317) 233-7761

Email: <pdurkin@isdh.IN.gov>

<http://www.in.gov/isdh/publications/llo/shortages/shortage.htm>

**[Iowa]{.underline}**

Carl Kulczyk

Iowa Department of Public Health

Bureau of Health Care Access

Lucas State Office Building

321 East 12^th^ Street, 5^th^ Floor

Des Moines, IA 50319-0075

Phone: (515) 281-7223

Fax: (515) 242-6383

Email: <ckulczyk@idph.state.ia.us>

<http://www.idph.state.ia.us/hpcdp/primary_care.asp>

**[Kansas]{.underline}**

Barbara Gibson

Office of Local & Rural Health

Kansas Department of Health and Environment

1000 Southwest Jackson, Suite 340

Topeka, KS 66612

Phone: (785) 296-0613

Fax: (785) 296-1231

Email: <bgibson@kdhe.state.ks.us>

<http://www.kdhe.state.ks.us/olrh/pc.htm>

**[Kentucky]{.underline}**

John Hensley

Department of Public Health

Health Care Access Branch

Division of Adult & Child Heath

275 East Main Street, HS2W-B

Frankfort, KY 40621

Phone: (502) 564-8966 x3773

Fax: (502) 696-5231

Email: <john.hensley@ky.gov>

<http://chfs.ky.gov/dph/ach/primarycare.htm>

**[Louisiana]{.underline}**

Gerrelda Davis

Bureau of Primary Care and Rural Health

Louisiana Department of Health & Hospitals

P.O. Box 3118

Baton Rouge, LA 70821-3118

Phone: (225) 342-1583

Fax: (225) 342-5839

Email: <gdavis@dhh.la.gov>

[www.pcrh.dhh.louisiana.gov](http://www.pcrh.dhh.louisiana.gov/)

**[Maine]{.underline}**

Charles Dwyer

Office of Rural Health & Primary Care

Maine Department of Health & Human Services

286 Water Street, Key Plaza

Augusta, ME 04333-0011

Phone: (207) 287-3287

Fax: (207) 287-5431

Email: <charles.dwyer@maine.gov>

<http://www.maine.gov/dhhs/bohodr/orhpcpge.htm>

**[Maryland]{.underline}**

Antoinette Coward

Department of Health and Mental Hygiene

Primary Care Organization

201 West Preston Street

Baltimore, MD 21201

Phone: (410 )767-5602

Fax: (410) 333-7501

Email: <cowarda@dhmh.state.md.us>

**[Massachusetts]{.underline}**

Julia Dyck

Office of Primary Care

Massachusetts Department of Public Health

250 Washington Street, 5^th^ Floor

Boston, MA 02108-4619

Phone: (617) 624-5224

Fax: (617) 624-6062

Email: <julia.dyck@state.ma.us>

**[Michigan]{.underline}**

Lonnie Barnett

Health Policy, Regulation, and Professions

Michigan Department of Community Health

Health Planning and Access to Care Section

Capitol View Building, 7^th^ Floor

201 Townsend

Lansing, MI 48913

Phone: (517) 241-2963

Fax: (517) 241-1200

Email: <barnettl@michigan.gov>

**[Minnesota]{.underline}**

Debra Jahnke

Office of Rural Health and Primary Care

Minnesota Department of Health

P.O. Box 64882

St. Paul, MN 55164-0882

Phone: 800-366-5424

Fax: (651) 201-3830

Email: <debra.jahnke@health.state.mn.us>

<http://www.health.state.mn.us/divs/chs/orh_home.htm>

**[Mississippi]{.underline}**

Alvin Harrion

Mississippi Department of Health

P.O. Box 1700

Jackson, MS 39215-1700

Phone: (601) 576-7216

Fax: (601) 576-7530

Email: <aharrion@msdh.state.ms.us>

**[Missouri]{.underline}**

Harold Kirbey

Office of Primary Care & Rural Health

Missouri Department of Health & Senior Services

920 Wildwood Drive

P.O. Box 570

Jefferson City, MO 65102-0570

Phone: 1-800-891-7415

Fax: (573) 522-8146

Email: <harold.kirbey@dhss.mo.gov>

[http://www.dhss.mo.gov](http://www.dhss.mo.gov/)

**[Montana]{.underline}**

John Schroeck

Montana Primary Care Office

Montana Department of Public Health & Human Sciences

P.O. Box 202951

Helena, MT 59620-2951

Phone: (406) 444-3934

Fax: (406) 444-7465

Email: <jschroeck@mt.gov>

**[Nebraska]{.underline}**

Thomas Rauner

Health and Human Services System

Office of Rural Health and Primary Care

301 Centennial Mall South

P.O. Box 95007

Lincoln, NE 68509-5007

Phone: (402) 471-0148

Fax: (402) 471-0180

Email:
[thomas.rauner@hhss.ne.gov](mailto:thomas.rauner@hhss.state.ne.us)

[www.hhss.ne.gov/orh](http://www.hhss.ne.gov/orh)

**[Nevada]{.underline}**

Judy Wright

Nevada State Health Division

Primary Care Development Center

3427 Goni Road, Suite 108

Carson City, NV 89706

Phone: (775) 684-4220 (Main)

Fax: (775) 684-4046

Email: <jwright@nvhd.state.nv.us>

<http://health2k.state.nv.us/primary>

**[New Hampshire]{.underline}**

Alisa Butler

Rural Health and Primary Care

29 Hazen Drive

Concord, NH 03301

Phone: (603) 271-5934

Fax: (603) 271-4506

Email: <agbutler@dhhs.state.nh.us>

[[http://www.dhhs.state.nh.us/DHHS/RHPC/pco.htm]{.underline}](http://www.dhhs.state.nh.us/DHHS/RHPC/pco.htm)

**[New Jersey]{.underline}**

Linda Anderson

New Jersey Department of Health & Senior Services

50 East State Street, 6^th^ Floor

P.O. Box 364

Trenton, NJ 08625-0364

Phone: (609) 292-1495

Fax: (609) 292-9599

Email: <linda.anderson@doh.state.nj.us>

**[New Mexico]{.underline}**

Kim Kinsey

New Mexico Department of Health

625 Silver, SW, Suite 201

Albuquerque, NM 87102

Phone: (505)841-5871

Fax: (505) 841-5885

Email: <kenbaht.kinsey@state.nm.us>

**[New York]{.underline}**

Barry Gray

New York Department of Health

Tower Building, Room 1084

Empire State Plaza

Albany, NY 12237-0053

Phone: (518) 473-4700

Fax: (518) 474-0572

Email: <bmg01@health.state.ny.us>

[http://www.nyhealth.gov](http://www.nyhealth.gov/)

**[North Carolina]{.underline}**

Serge Dihoff

Office of Research, Demonstrations and Rural Health Development

North Carolina Department of Health & Human Services

311 Ashe Avenue

Raleigh, NC 27606

Phone: (919) 715-7632

Fax: (919) 733-8300

Email: <serge.dihoff@ncmail.net>

**[North Dakota]{.underline}**

Gary Garland

Office of Community Assistance

North Dakota Department of Health

600 E. Boulevard, Department 301

Bismarck, ND 58505-0200

Phone: (701) 328-4839

Fax: (701) 328-1890

Email: <ggarland@state.nd.us>

**[Ohio]{.underline}**

Coleen Schwartz

Primary Care and Rural Health Program

Ohio Department of Health

246 North High Street, 6^th^ Floor

P.O. Box 118

Columbus, OH 43216-0118

Phone: (614) 728-3700

Fax: (614) 995-4235

Email: <coleen.schwartz@odh.ohio.gov>

**[Oklahoma]{.underline}**

Mike Brown

Office of Primary Care

Oklahoma State Department of Health

1000 NE 10^th^ Street, Room 511

Oklahoma City, OK 73117

Phone: (405) 271-8428

Fax: (405) 271-5493

Email: <mikebr@health.ok.gov>

**[Oregon]{.underline}**

Joel Young

Primary Care Office

Department of Human Services

Health Systems Planning

800 NE Oregon Street, Suite 930

Portland, OR 97232

Phone: (971) 673-1222

Fax: (971) 673-1299

Email: <joel.young@state.or.us>

**[Pennsylvania]{.underline}**

Marina Matthew

Pennsylvania Department of Health

Bureau of Health Planning

Division of Health Professions Development

Room 1033 Health & Welfare Building, 7^th^ & Forster Streets

Harrisburg, PA 17120

Phone: (717) 772-5298

Fax: (717) 705-6525

Email: <mmatthew@state.pa.us>

[www.health.state.pa.us/pco](http://www.health.state.pa.us/pco)

**[Puerto Rico]{.underline}**

Nadia Gardana

Puerto Rico Department of Health

Office of Federal Affairs

Room 131, Building A

PR Medical Center

P.O. Box 70139

San Juan, PR 00936-8139

Phone: (787) 274-7735

Fax: (787) 274-6864

Email: <ngardana@salud.gov.pr>

**[Rhode Island]{.underline}**

Mary Anne Miller

Office of Primary Care

Rhode Island Department of Health

3 Capitol Hill, Room 408

Providence, RI 02908

Phone: (401) 222-7625

Fax: (401) 222-4415

Email: <maryanne.miller@health.ri.gov>

[www.health.ri.gov](http://www.health.ri.gov/)

**[South Carolina]{.underline}**

Mark Jordan

Office of Primary Care

South Carolina Department of Health & Environmental Control

Mills/Jarrett Complex, Box 101106

Columbia, SC 29211

Phone: (803) 898-0766

Fax: (803) 898-0445

Email: <jordanma@dhec.sc.gov>

**[South Dakota]{.underline}**

Bernard Osberg

Office of Rural Health

South Dakota Department of Health

207 E. Missouri Avenue, #1A

Pierre, SD 57501

Phone: (605) 773-3366

Fax: (605) 773-2680

Email: <bernie.osberg@state.sd.us>

[www.ruralhealth.sd.gov](http://www.ruralhealth.sd.gov/)

**[Tennessee]{.underline}**

Patrick Lipford

Tennessee Department of Health

Cordell Hull Building

425 5^th^ Avenue, N, 6^th^ Floor

Nashville, TN 37247

Phone: (615) 741-0388

Fax: (615) 253-2100

Email: <patrick.lipford@state.tn.us>

**[Texas]{.underline}**

Connie Berry

Texas Primary Care Office

Texas Department of State Health Services

1100 West 49^th^ Street, M328

Austin, TX 78726

Mail code: 1937

Phone: (512) 458-7518

Fax: (512) 458-7658

Email: <connie.berry@dshs.state.tx.us>

**[Utah]{.underline}**

Don Beckwith

Office of Primary Care & Rural Health

Utah Department of Health

P.O. Box 142005

Salt Lake City, UT 84114-2005

Phone: (801) 538-6818

Fax: (801) 538-6387

Email: <dbeckwith@utah.gov>

<http://health.utah.gov/primarycare>

**[Vermont]{.underline}**

Denis Barton

Division of Health Improvement

Office of Rural Health and Primary Care

Vermont Department of Health

108 Cherry Street, P.O. Box 70

Burlington, VT 05402-0070

Phone: (802) 951-4006

Fax: (802) 651-1634

Email: <dbarton@vdh.state.vt.us>

[www.healthyvermonters.org](http://www.healthyvermonters.org/)

**[Virgin Island]{.underline}**

Lorna Sutton

Virgin Islands Primary Health Care Office

Government House

21-22 Kongens Gade

St. Thomas, VI 00802

Phone: (340) 715-1611

Fax: (340) 715-3219

Email: <lornali96@earthlink.net>

**[Virginia]{.underline}**

Rene Cabral-Daniels

Virginia Department of Health

Office of Health Policy and Planning

109 Governors Street, Suite 1016 East, 10^th^ Floor

Richmond, VA 23219

Phone: (804) 864-7425

Fax: (804) 864-7440

Email: <rene.cabraldaniels@vdh.virginia.gov>-

**[Washington]{.underline}**

Mary Looker

Office of Community & Rural Health

Washington State Department of Health

P.O. Box 47834

Olympia, WA 98504-7834

Phone: (360) 236-2808

Fax: (360) 664-9273

Email: <mary.looker@doh.wa.gov>

[www.doh.wa.gov/hsqa/ocrh](http://www.doh.wa.gov/hsqa/ocrh)

**[West Virginia]{.underline}**

David Haden

Division of Primary Care

Office of Community and Rural Health Services

350 Capitol Street, Room 515

Charleston, WV 25301-3716

Phone: (304) 558-7127

Fax: (304) 558-1437

Email: <davidhaden@wvdhhr.org>

<http://www.wvochs.org/dpc/>

**[Wisconsin]{.underline}**

Anne Dopp

Bureau of Local Health Support & Emergency Medical Services

Division of Public Health

1 West Wilson Street, Room 118

Madison, WI 53701

Phone: (608) 267-7121

Fax: (608) 261-6392

Email: <doppaw@dhfs.state.wi.us> --

**[Wyoming]{.underline}**

Lynne Weidel

Office of Rural Health

Wyoming Department of Health

Hathaway Building

6101 Yellowstone Road, Ste 510

Cheyenne, WY 82002

Phone: (307) 777-8940

Fax: (307) 777-8545

Email: [lweide@state.wy.us](mailto:lweidel@state.wy.us)

**III. NATIONAL ORGANIZATIONS**

Jeffrey Cabellero

Executive Director

Association of Asian Pacific Community Health Organizations 

300 Frank Ogawa Plaza, Suite 620

Oakland, CA  94612

Phone:  510-272-9536

Email:  <jeffc@aapcho.org>

[www.aapcho.org](http://www.aapcho.org/) 

Paul E. Jarris, MD, MBA

Executive Director

Association of State and Territorial Health Officers

1275 K Street, N.W., Suite 800

Washington, DC  20005-4006

Phone:  202-371-9090

Email:  <pjarris@astho.org>

[www.astho.org](http://www.astho.org/)

Oscar Gomez

CEO

Farmworker Health Services, Inc

405 14^th^ Street, Suite 809

Oakland, CA  94612

Phone:  510-268-0091

Email:  oscar@farmworkerhealth.org

[www.farmworkerhealth.org](http://www.farmworkerhealth.org/)

Shelley Davis

Deputy Director

Farmworker Justice

1126 16^th^ Street NW,Suite 270

Washington, DC 20036

Phone: 202-293-542-

Email: sdavis@nclr.org

Karen Mountain, M.B.A., M.S.N, RN

Chief Executive Officer

Migrant Clinicians Network

101 Land Creek Cove

Austin, TX  78746

Phone:  512-327-2017

Email:  <kmountain@migrantclinician.org>

[www.migrantclinician.org](http://www.migrantclinician.org/)

Gayle A. Lawn-Day, PhD

Executive Director

Migrant Health Promotion, Relampago School

P.O. Box 337

Progresso, TX 78579

Phone:  956-565-0002

Email: <glawnday@migranthealth.org>

[www.migranthealth.org](http://www.migranthealth.org/)

Laura Brey

Director of Training

National Assembly for School-Based Health Centers\
666 11th Street, N.W., Suite 735

Washington,  DC  20001

Phone:  202-638-5872

Email:  <lbrey@nasbhc.org>

[www.nasbhc.org](http://www.nasbhc.org/)

Pamela J. Byrnes, PhD

National Association of Community Health Centers

50 South Washington Avenue

Niantic, CT 06357

Ph:  860-739-9224

Fax: 860-691-1388

Email:  <pbyrnes@nachc.com>

[www.nachc.com](http://www.nachc.com/)

Patrick Libbey

Executive Director

National Association of County and City Health Officials

1100 17th Street, N.W., 2nd Floor

Washington,  DC  20036

Phone:  202-783-5550

Email:  <plibbey@naccho.org>

[www.naccho.org](http://www.naccho.org/)

Bobbi Ryder

President and CEO

National Center for Farmworker Health

1770 FM 967

Buda, TX  78610

Phone:  512-312-5451

Email:  <ryder@ncfh.org>

[www.ncfh.org](http://www.ncfh.org/)

William Pound

Executive Director

National Conference of State Legislators

7700 East First Place

Denver, CO 80230-7143

Phone:  303- 364-7700

Email:  <William.pound@ncsl.org>

[www.ncsl.org](http://www.ncsl.org/)

Karen E. Rotondo

New Access Coordinator

National Healthcare for the Homeless Council

1716 Greenwood Avenue/P.O. Box 60427

Nashville, TN  37206-0427

Phone: 413-219-8747

Email: <kerotondo@nhchc.org>

[www.nhchc.org](http://www.nhchc.org/)

Rosemary McKenzie

Project Director

National Rural Health Association

521 East 63^rd^ Street

Kansas City,  MO  64110

Phone:  816-756-3140

Email:  <rmckenzie@nrharural.org>

[www.nrharural.org](http://www.nrharural.org/)

Catherine Hess

Senior Program Director

National Academy for State Health Policy

1233 20^th^ Street, NW, Suite 303

Washington, DC 20036-2304

Phone:  202-903-0101

Email:  <chess@nashp.org>

[www.nashp.org](http://www.nashp.org/)

Deborah Murphy

Project Director

National Center for Health Care for Public Housing Residents

North American Management

2111 Wilson Blvd., Suite 323

Arlington, Virginia  22201

Phone: 703-812-8822

Email: <dmurphy@nambco.com>

[www.nambco.com/hphr](http://www.nambco.com/hphr)

#######  {#section-32}

# APPENDIX H:

# SERVICE AREA COMPETITION DEFINITIONS 

## SERVICE AREA COMPETITION DEFINITIONS

**Actual accrued income:** the amount received by the applicant for this
type of payor in the most recent 12 month period for which the applicant
has data.

**Administrative support staff:** Form 2 uses this term. It refers to
all other members of the administrative team (all fiscal staff and the
staff of the key administrative officers) *plus* the medical records
staff.

**Budget period**: is each 12-month period within an approved project
period (see below for definition). A complete budget presentation for
each budget period in the proposed project period should be included in
the application.

**Census tracts:** are small, relatively permanent statistical
subdivisions of a county designed to be relatively homogeneous units
with respect to population characteristics, economic status, and living
conditions, census tracts average about 4,000 inhabitants. Tracts are
delineated by a local committee of census data users for the purpose of
presenting data. Census tract boundaries normally follow visible
features, but may follow governmental unit boundaries and other
non-visible features in some instances; they always nest within
counties. Information to determine the census tracts with a given
service area is available online at:
<http://www.census.gov/geo/www/tractez.html>.

**Cultural competency:** Applicants are expected to describe a
[culturally and linguistically appropriate services]{.underline} plan
that meets the expectations outlined in Section I.B.2 of PIN 98-23,
Health Center Program Expectations, that states:

> *Health centers serve culturally and linguistically diverse
> communities and many serve multiple cultures within one center.
> Although race and ethnicity are often thought to be dominant elements
> of culture, Health Centers should embrace a broader definition to
> include language, gender, socio-economic status, sexual orientation,
> physical and mental capacity, age, religion, housing status, and
> regional differences. Organizational behaviors, practices, attitudes,
> and policies across all Health Center functions must respect and
> respond to the cultural diversity of communities and clients served.
> Health centers should develop systems that ensure participation of the
> diverse cultures in their community, including participation of
> persons with limited English-speaking ability, in programs offered by
> the Health Center. Health centers should also hire culturally and
> linguistically appropriate staff.*

HRSA encourages applicants to utilize existing, effective program
models, such as lay health worker or *Promotora de Salud* programs, to
incorporate the above strategies into their proposed programs. Lay
health worker/*Promotora de Salud* programs have been shown to be an
effective means of educating hard-to-reach populations, increasing
access through information and referrals, and conducting follow up.
Generally, these programs involve a full-time staff coordinator who
recruits, trains, and supervises a group of 8-10 part-time lay health
workers who are members of the target population. Trained lay health
workers, in turn, provide education, referrals, follow-up, case
management, and other outreach to their fellow community members.

**Existing grantee:** is an organization currently funded under section
330 whose project period expires or after October 31, 2007 and before
October 1, 2008. Existing grantees may include any 'new starts' (new
grantee awarded through the New Access Point funding opportunity) whose
project period is ending on or after October 31, 2007 and before October
1, 2008.

**Homeless:** A homeless individual means an individual who lacks
housing (without regard to whether the individual is a member of a
family), including an individual whose primary residence during the
night is a supervised public or private facility that provides temporary
living accommodations and an individual who is a resident in
transitional housing.

**Migratory and Seasonal farmworker:** Migratory agricultural worker
means an individual whose principal employment is in agriculture, who
has so been employed in the last 24 months, and who establishes for the
purposes of such employment a temporary abode. Seasonal agricultural
worker means an individual whose principal employment is in agriculture
on a seasonal basis and who is not a migrant agricultural worker.

**Non-grant funds:** used on the SF-424 form. For the purpose of this
submission, "non-grant funds" include grant funds from other
governmental agencies and non-330 funding.

**Project period:** is defined as the total time for which Federal grant
support has been approved.

**Primary care services**: Under Section 330 of the Public Health
Service Act the term "required primary health services" means: 

(i)         basic health services which, for the purposes of this
section, shall consist of -

> \(I\) health services related to family medicine, internal medicine,
> pediatrics, obstetrics, or gynecology that are furnished by physicians
> and where appropriate, physician assistants, nurse practitioners, and
> nurse midwives;
>
> \(II\) diagnostic laboratory and radiologic services;
>
> \(III\) preventive health services, including---
>
> (aa) prenatal and perinatal services;
>
> (bb) appropriate cancer screening;
>
> \(cc\) well-child services;
>
> (dd) immunizations against vaccine-preventable diseases;
>
> (ee) screenings for elevated blood lead levels, communicable diseases,
> and cholesterol;
>
> (ff) pediatric eye, ear, and dental screenings to determine the need
> for vision and hearing correction and dental care;
>
> (gg) voluntary family planning services; and
>
> (hh) preventive dental services;
>
> \(IV\) emergency medical services; and
>
> \(V\) pharmaceutical services as may be appropriate for particular
> centers;

\(ii\) referrals to providers of medical services (including specialty
referral when medically indicated) and other health-related services
(including substance abuse and mental health services);

\(iii\) patient case management services (including counseling,
referral, and follow-up services) and other services designed to assist
health center patients in establishing eligibility for and gaining
access to Federal, State, and local programs that provide or financially
support the provision of medical, social, housing, educational, or other
related services;

\(iv\) services that enable individuals to use the services of the
health center (including outreach and transportation services and, if a
substantial number of the individuals in the population served by a
center are of limited English-speaking ability, the services of
appropriate personnel fluent in the language spoken by a predominant
number of such individuals); and

\(v\) education of patients and the general population served by the
health center regarding the availability and proper use of health
services.

**Scope of project:**  Defines the activities that the total approved
grant-related project budget supports.  Specifically, the scope of
project defines the service sites, services, providers, service area(s)
and target population for which section 330 grant funds may be used. 

**Service area:** The concept of a service or "catchment" area has been
part of the Health Center Program since its beginning.  In general, the
service area is the area in which the majority of the applicant's
patients reside.  The Health Center Program's authorizing statute
requires that each grantee periodically review its catchment area to:

 

> **(i)** ensure that the size of such area is such that the services to
> be provided through the center (including any satellite) are available
> and accessible to the residents of the area promptly and as
> appropriate;

 

> **(ii)** ensure that the boundaries of such area conform, to the
> extent practicable, to relevant boundaries of political subdivisions,
> school districts, and Federal and State health and social service
> programs;  and
>
>  
>
> **(iii)** ensure that the boundaries of such area eliminate, to the
> extent possible, barriers to access to the services of the center,
> including barriers resulting from the area\'s physical
> characteristics, its residential patterns, its economic and social
> grouping, and available transportation. **Public Health Service Act
> sec. 330(k)(3)(J)**

 

The service area should, to the extent practicable, be identifiable by
census tracts.  Describing service areas by census tracts is necessary
to enable analysis of service area demographics.  Service areas may also
be described by other political or geographic subdivisions (e.g. county,
township, zip codes as appropriate).  The service area must be
designated in full or in part as a Medically Underserved Area or contain
a designated Medically Underserved Population (MUP).  While applicants
may serve patients from outside their service area, they must serve all
residents of the service area,[^14] regardless of ability to pay.

**Service site:** is any place where an applicant, either directly or
through a subrecipient or contract arrangement, provides primary health
care services to a defined service area or target population. Service
sites are defined as locations where [all]{.underline} of the following
conditions are met:

-   encounters are generated by documenting in the patients' medical
    record face-to-face contacts between patients and providers;

-   providers exercise independent judgment in the provision of services
    to the patient;

-   services are provided directly by or on behalf of the grantee, whose
    governing board retains control and authority over the provision of
    the services at the location; and

-   services are provided on a regularly scheduled basis (e.g., daily,
    weekly, first Thursday of every month).[^15] However, there is no
    minimum number of hours per week that services must be available at
    an individual site/location.

-   Administrative offices or locations that do not provide direct
    health care services are [not]{.underline} service sites.

**Sliding discount:** Discounts (also referred to as "sliding fee
scales") must be provided to self-pay patients at or below 200% of the
Federal Poverty Level (see the Federal poverty guidelines at
[[http://aspe.hhs.gov/poverty/]{.underline}](http://aspe.hhs.gov/poverty/))
based on their ability to pay. Those at or below 100% of the Federal
poverty level receive 100% discounts (but may pay a nominal fee).
Discounts may also be applied to co-payments for insured patients based
on their ability to pay. Grantees establish their own schedule of
discounts based on income and family size as it relates to the poverty
with the discount "sliding" downwards from 100% to 0%. The number of
distinct categories of discounts is chosen by the grantee. Discounts may
not be provided to patients over 200% of the Federal poverty level.

**Sparsely populated areas:** is a geographical area with 7 people or
less per square mile for the entire service area.

It is recognized that the recommended level of staffing and/or services
may not be supportable in sparsely populated areas. Therefore,
alternative methods of providing necessary support for isolated
providers, including participation in rural service delivery networks
may be considered appropriate. For example, applicants that by
themselves may not be able to meet the staffing recommendations and/or
service requirements may, through formal agreements regarding clinical
and referral arrangements or strong collaborative relationships with
other local providers, be considered to have met the staffing level
recommendations and/or service requirements.

In addition, applicants from sparsely populated rural or frontier areas
may request a waiver from the governing board requirements under section
330(k)(3)(H)(iii). However, such applicants must clearly demonstrate why
any or all of the governing board requirements cannot be met and must
provide a documented plan for soliciting community input in the
operation of the applicant.

**Strategic planning:** Sets the course for the organization's future
based on market and internal information.

**Subrecipient:** is an organization that receives a sub-award from the
section 330 grantee. In a subrecipient relationship, each organization
(grantee and subrecipients) must be in compliance with all applicable
section 330 requirements in order to qualify as a federally qualified
health center.

**Target population:** A target population is usually a subset of the
entire service area population but may include all residents of the
service area. The description of the target population should include
the major health problems of the target population and should serve as
the basis for the applicant\'s service delivery plan. The target
population for an applicant may be composed of a particular
ethnic/socio-economic group or may be composed of a variety of different
ethnic/socio-economic groups. In all cases, however, the applicant must
demonstrate that services are equally available to everyone. The target
population may not be limited in terms of age or gender.

-   **For CHCs** target population refers to the individuals within the
    service area to whom it will direct its service delivery plan.

-   **For MHCs** the target population refers to the migratory and
    seasonal farmworker individuals and their family members within the
    service area to whom it will direct its service delivery plan.

-   **For HCHs** the target population refers to the homeless
    individuals within the service area to whom it will direct its
    service delivery plan.

-   **For PHPCs** the target population refers to the residents of one
    or more public housing developments and the surrounding areas to
    whom it will direct its service delivery plan.

All applicants must provide access to the full-range of required
services for all life cycle groups. This requirement does not preclude a
more limited target population or range of services for a particular
service delivery site. In such a case, assurance must be provided that
all patients have access to the full-range of required services and
necessary supplemental services within the applicant\'s current service
delivery capacity, or through appropriate referrals.

#######  {#section-33}

#######  {#section-34}

#######  {#section-35}

# APPENDIX I:

# Summary of Program requirements and expectations

### Appendix I:

### Summary of Program requirements and expectations

The following list provides a summary of key program requirements and
expectations, the majority of which should be addressed in the
application. **[This summary is not comprehensive]{.underline}** and
therefore applicants are encouraged to review:

-   Consolidated Health Center Program Statute: section 330 of the
    Public Health Service Act (42 U.S.C. §254b)

-   Program Regulations (42 CFR 51c and 42 CFR 56.201-56.604 for
    Community and Migrant Health Centers)

-   Policy Information Notice (PIN) \# 98-23: Health Center Program
    Expectations

+---+------------------------------------------------------------------+
| * |                                                                  |
| * |                                                                  |
| n |                                                                  |
| e |                                                                  |
| e |                                                                  |
| d |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| 1 | Applicant demonstrates the need for primary health care services |
| . | in the service area and/or target population.                    |
|   |                                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 2 | Applicant serves, in whole or in part, a designated MUA or MUP.  |
| . | *(Requested, not required for HCH, PHPC or MHC applicants).*     |
|   |                                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 3 | Service delivery site(s) is or will be open to provide services  |
| . | at the times that meet the needs of the majority of potential    |
|   | patients.                                                        |
|   |                                                                  |
+---+------------------------------------------------------------------+
| * |                                                                  |
| * |                                                                  |
| S |                                                                  |
| e |                                                                  |
| r |                                                                  |
| v |                                                                  |
| i |                                                                  |
| c |                                                                  |
| e |                                                                  |
| s |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| 4 | All services are available to all persons in the service area or |
| . | target population regardless of age, gender, or the patient's    |
|   | ability to pay.                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 5 | Applicant provides ready access to all of the required primary,  |
| . | preventive and supplemental/enabling health services, without    |
|   | regard to ability to pay, either directly on-site or through     |
|   | established arrangements and referrals.                          |
+---+------------------------------------------------------------------+
| 6 | Applicant provides all additional health services as appropriate |
| . | and necessary.                                                   |
|   |                                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 7 | Applicant has services designed to assist patients in            |
| . | establishing eligibility for and gaining access to Federal,      |
|   | State and local programs that provide or financially support the |
|   | provision of medical, social, educational or other related       |
|   | services.                                                        |
+---+------------------------------------------------------------------+
| 8 | Applicant collaborates appropriately with other health and       |
| . | social service providers in their area.                          |
|   |                                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 9 | Applicant maintains a core staff of primary care providers       |
| . | appropriate for the population served.                           |
|   |                                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 1 | Applicant's physicians have admitting privileges at one or more  |
| 0 | referral hospital(s), or other such arrangement to ensure        |
| . | continuity of care.                                              |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 1 | Applicant organization use a charge schedule with a              |
| 1 | corresponding discount schedule based on income for persons      |
| . | between 100 percent and 200 percent of the Federal poverty level |
|   | and no charge for those below 100 percent of the Federal poverty |
|   | level.                                                           |
+---+------------------------------------------------------------------+
| 1 | Applicant provides professional coverage during hours when the   |
| 2 | center is closed.                                                |
| . |                                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 1 | Applicant has an ongoing quality improvement system that         |
| 3 | includes clinical services and management, and that maintains    |
| . | the confidentiality of patient records.                          |
|   |                                                                  |
+---+------------------------------------------------------------------+
| * |                                                                  |
| * |                                                                  |
| M |                                                                  |
| a |                                                                  |
| n |                                                                  |
| a |                                                                  |
| g |                                                                  |
| e |                                                                  |
| m |                                                                  |
| e |                                                                  |
| n |                                                                  |
| t |                                                                  |
| a |                                                                  |
| n |                                                                  |
| d |                                                                  |
| f |                                                                  |
| i |                                                                  |
| n |                                                                  |
| a |                                                                  |
| n |                                                                  |
| c |                                                                  |
| e |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| 1 | Applicant has clear lines of authority from the Board to a chief |
| 4 | executive (President, Chief Executive Officer or Executive       |
| . | Director) who delegates, as appropriate, to other management and |
|   | professional staff.                                              |
+---+------------------------------------------------------------------+
| 1 | Applicant has systems which accurately collect and organize data |
| 5 | for reporting and which support management decision-making and   |
| . | which integrate clinical, utilization and financial information  |
|   | to reflect the operations and status of the organization as a    |
|   | whole.                                                           |
+---+------------------------------------------------------------------+
| 1 | Applicant has accounting and internal control systems            |
| 6 | appropriate to the size and complexity of the organization       |
| . | reflecting Generally Accepted Accounting Principles (GAAP) and   |
|   | separating functions appropriate to organizational size to       |
|   | safeguard assets.                                                |
+---+------------------------------------------------------------------+
| 1 | Applicant assures that an annual independent financial audit is  |
| 7 | performed in accordance with Federal audit requirements.         |
| . |                                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 1 | Applicant maximizes revenue from third party payers and from     |
| 8 | patients to the extent they are able to pay.                     |
| . |                                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 1 | Applicant has written billing, credit and collection policies    |
| 9 | and procedures.                                                  |
| . |                                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 2 | Applicant has appropriate oversight and authority over all       |
| 0 | contracted services (including management agreements,            |
| . | administrative services contracts, etc.).                        |
|   |                                                                  |
+---+------------------------------------------------------------------+
| * |                                                                  |
| * |                                                                  |
| G |                                                                  |
| o |                                                                  |
| v |                                                                  |
| e |                                                                  |
| r |                                                                  |
| n |                                                                  |
| a |                                                                  |
| n |                                                                  |
| c |                                                                  |
| e |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| 2 | Applicant has a governing board that is composed of individuals, |
| 1 | a majority of who are or will be served by the organization and, |
| . | who as a group, represent the individuals being serviced by the  |
|   | organization in terms of race, ethnicity and gender? *(May be    |
|   | waived for eligible applicants. See Form 6- B)*                  |
+---+------------------------------------------------------------------+
| 2 | Applicant's governing board has at least 9 but no more than 25   |
| 2 | members, as appropriate for the size and complexity of the       |
| . | organization and the diversity of the community served.          |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 2 | Applicant's governing board has the required authority and       |
| 3 | responsibility to oversee the operation of the organization.     |
| . |                                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 2 | Applicant's governing board is required to meet monthly. *(May   |
| 4 | be waived for eligible applicants. See Form 6- B)*               |
| . |                                                                  |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 2 | Applicant's governing board has the authority to approve the     |
| 5 | submission of annual grant application and the annual health     |
| . | center budget.                                                   |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 2 | Applicant's governing board has the authority to select the      |
| 6 | services provided by the health center and determine the hours   |
| . | during which services are provided.                              |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 2 | Applicant's governing board has the authority to approving the   |
| 7 | selection and dismissal of the health center's chief executive   |
| . | officer or Program Director and evaluate his/her performance.    |
|   |                                                                  |
+---+------------------------------------------------------------------+
| 2 | Applicant's governing board has the authority to establish       |
| 8 | general policies for the health center, which include, but are   |
| . | not limited to: Personnel, Health Care, Fiscal, and Quality      |
|   | Assurance/ Improvement policies *(Some fiscal and personnel      |
|   | policies may be retained in the case of public entities).*       |
+---+------------------------------------------------------------------+

[^1]: See PIN 98-12: Implementation of the 330 Governance Requirements
    for additional information.

[^2]: Public centers have also been referred to as "public entities" in
    the past.

[^3]:

[^4]: Applicants currently receiving section 330 funding and applying to
    serve their current service area who are changing the delivery
    manner of services resulting in a service being added (e.g. directly
    providing or paying for a service that was previously provided by
    referral without payment) or deleted (e.g. providing a service by
    referral without payment that was previously directly provided or
    paid for by the applicant) should submit a change in scope request
    for prior approval. The change in scope application must be emailed
    to <bphcscope@hrsa.gov> and a signed original must be sent to the
    HRSA's Division of Grants Management Operations with a courtesy copy
    to the Project Officer.

[^5]: As defined in Appendix H: Service Area Competition Definitions.

[^6]: As stated in PIN 98-23: Health Center Program Expectations, PIN
    97-27: Affiliation Agreements of Community and Migrant Health
    Centers, and/or 98-24: Amendment to PIN 97-27 Regarding Affiliation
    Agreements of Community and Migrant Health Centers. Applicants are
    encouraged to review Appendix I for additional information on
    program requirements and expectations.

[^7]: In cases where a public entity has a co-applicant board, the
    public entity and co-applicant board must have a formal co-applicant
    agreement that stipulates: roles, responsibilities and the
    delegation of authorities; and any shared roles and responsibilities
    of each party in carrying out the governance functions.

[^8]: As stated in PIN 98-23: Health Center Program Expectations, PIN
    97-27: Affiliation Agreements of Community and Migrant Health
    Centers, and/or 98-24: Amendment to PIN 97-27 Regarding Affiliation
    Agreements of Community and Migrant Health Centers Applicants are
    encouraged to review Appendix I for additional information on
    program requirements and expectations.

[^9]: Governance requirements do not apply to Indian tribes or tribal
    organizations under the Indian Self-Determination Act or an urban
    Indian organization under the Indian Health Care Improvement Act.

[^10]: ^?^ Applicants that are public centers whose board cannot
    directly meet health center governance requirements [are permitted
    to establish a separate "co-applicant" health center governing board
    that meets all the section 330 governance requirements.]{.underline}

    In the co-applicant arrangement, the public center receives the
    section 330 grant and the co-applicant board serves as the "health
    center board."

    Together, the two collectively are referred to as the "health
    center."

    The co-applicant board members should be identified and documented
    in the entity's application (using FORM 6-Part A: Board Member
    Characteristics).

    The public center and health center boards must have a formal
    co-applicant agreement that stipulates: roles, responsibilities and
    the delegation of authorities; and any shared roles and
    responsibilities of each party in carrying out the governance
    functions.

[^11]: The co-applicant health center board must meet all the size and
    composition requirements, perform all the duties of and retain all
    the authorities expected of governing boards [except that the public
    center is permitted to retain responsibility for establishing
    general policies (fiscal and personnel policies) for the health
    center.]{.underline}

[^12]: See PIN 98-12: Implementation of the 330 Governance Requirements
    for additional information

[^13]: Applicants currently receiving section 330 funding and applying
    to serve their current service area should ensure that their
    application reflects their current approved scope of project. Any
    proposed changes in scope requiring prior approval MUST be submitted
    under separate cover. The change in scope application must be
    emailed to <bphcscope@hrsa.gov> and a signed original must be sent
    to the HRSA's Division of Grants Management Operations with a
    courtesy copy to the Project Officer. Please refer to the most
    recent guidance on this subject contained in PIN 2002-07: Scope of
    Project Policy (available onsite at
    [www.bphc.hrsa.gov](http://www.bphc.hrsa.gov/)), or contact
    <BPHCscope@hrsa.gov> for more information.

[^14]: Health centers receiving funding only under section 330(g), (h),
    and/or (i) of the PHS Act are not subject to the requirement to
    serve all residents of the service area.

[^15]: Note the statutory requirement in section 330(k)(3) of the PHS
    Act that "primary health services of the center will be available
    and accessible in the catchment area of the center promptly, as
    appropriate, and in a manner which assures continuity." In addition,
    note the regulatory requirement in 42 CFR 51c.303(m) that health
    centers "must be operated in a manner calculated \... to maximize
    acceptability and effective utilization of services."