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

**Health Resources and Services Administration**

Bureau of Primary Health Care

New Access Points in Programs Funded

Under the Health Centers Consolidation Act of 1996

> NEW ACCESS POINTS (NAP)

***NEW GRANT COMPETITION***

*Announcement Number HRSA 07-067*

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

**NEW ACCESS POINTS APPLICATION GUIDANCE**

Fiscal Year 2007

**Application Due Date in Grants.gov: December 6, 2006**

**Date of Issuance: *October 6, 2006***

> *Guidance and Programmatic Contact:*
>
> Preeti Kanodia
>
> Public Health Analyst
>
> Division of Policy and Development
>
> Telephone: 301/594-4300
>
> Fax: 301/594-4997
>
> preeti.kanodia@hrsa.hhs.gov

[]{.mark}

> Authority: Public Health Service Act, Title III, section 330, 42U.S.C.
> 254b

**EXECUTIVE SUMMARY:**

This application guidance details the eligibility requirements, review
criteria and awarding factors for organizations seeking a grant for
operational support of new access points in fiscal year (FY) 2007. This
application guidance supercedes Program Information Notice (PIN) 2005-01
and announcement number HRSA-05-101 used to detail the requirements,
review criteria and awarding factors for organizations seeking
operational support of a new access point in FY 2005.

**FY 2007, the following differences should be noted from
theHRSA-05-101:**

-   There will be only one competitive cycle for new access point
    funding, with a new application due date established.

-   Applications MUST be submitted electronically through the Grants.gov
    website.

-   The review process and review criteria have been updated.

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

An important element of the Health Resources and Services
Administration's (HRSA) commitment to improving and expanding access to
needed primary health care services is the support of new access points
for the delivery of primary health care services for the underserved.
Even though action on the FY 2007 appropriation has not been completed,
HRSA anticipates being able to accept applications from organizations
seeking a grant for operational support for new health center access
points under the Consolidated Health Center Program (i.e., Community
Health Center (CHC), Migrant Health Center (MHC), Health Care for the
Homeless (HCH), and Public Housing Primary Care (PHPC) Programs)
authorized under section 330 of the Public Health Service (PHS) Act, as
amended.

Organizations eligible to compete include public or nonprofit private
entities, including tribal, faith-based and community-based
organizations. All applicants are expected to demonstrate compliance
with the applicable requirements of section 330 of the PHS Act, the
implementing regulations and HRSA Program Expectations. Applications may
be submitted for consideration from new organizations or organizations
currently receiving funding under section 330.

President Bush's Health Centers Initiative, which began in FY 2002, will
increase health care access to 1,200 of the Nation's neediest
communities through new and/or significantly expanded health center
access points over five years. One way to achieve this goal is through
the creation of new access points for the provision of comprehensive
primary and preventive health care services in areas of high need that
will improve the health status and decrease health disparities of the
medically underserved populations to be served.

Based on the successes of this first Initiative, a second initiative is
expected to begin in FY 2007 by targeting the Nation's poorest counties
through the Consolidated Health Center Program. The President's High
Poverty Counties Initiative contains two components, New Access Points
and Planning Grants. Separate application guidance documents
(HRSA-07-069 and HRSA-07-066 respectively) detail the expectations,
eligibility requirements, review criteria and awarding factors for
organizations seeking a high poverty county new access point or planning
grant in FY 2007.

President Bush's fiscal year (FY) 2007 budget proposes an increase of
\$181 million in the appropriation for the Consolidated Health Center
Program authorized under section 330 of the PHS Act. Note that
Congressional action on the FY 2007 appropriation has not been
completed. However, HRSA anticipates that approximately \$61 million
will be available to support approximately 102 new access point grant
awards in FY 2007.

As mentioned above, separate application guidance will be issued for
funding opportunities under the President's High Poverty Counties
Initiative. **All applicants requesting new access point funds under the
President's Health Centers Initiative must use this guidance.** It
should be reviewed thoroughly prior to making a decision to apply.
Competitive new access point applications will demonstrate a high level
of need in their community, present a sound proposal to meet this need,
show that the organization is ready to rapidly initiate the proposal,
display responsiveness to the health care environment of the service
area and demonstrate collaborative and coordinated delivery systems for
the provision of health care to the underserved in their communities.

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 <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 you are seeking relief for. HRSA and its Grants Application
Center (GAC) will only accept paper applications from applicants that
received prior written approval.

**Applications must be submitted by 8:00 P.M. ET on December 6, 2006 and
indicate the application is for HRSA-07-067: NAP.** 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 as having met the deadline if
successfully transmitted electronically by your organization's
Authorizing Official through Grants.gov on or before the deadline date
and time, and the signed SF-424/5161 Face Sheet is received by HRSA no
later than five days after the day of submission in Grants.gov.
Applications submitted electronically after the due date and time will
not be accepted for processing and will be returned without
consideration.

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.
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.**

[]{.mark}

If you have questions regarding the FY 2007 new access point application
and/or the review process described in this application guidance please
call Preeti Kanodia in the Division of Policy and Development on (301)
594-4300 or PREETI.KANODIA@HRSA.HHS.GOV.

# Guidance Table of Contents {#guidance-table-of-contents .unnumbered}

[Guidance Table of Contents 1](#guidance-table-of-contents)

[I. Funding Opportunity Description and General Information
1](#funding-opportunity-description-and-general-information)

[Purpose 1](#__RefHeading___Toc143937351)

[Background 1](#background)

[Expected Results 1](#expected-results)

[Specific Requirements/Expectations
1](#specific-requirementsexpectations)

[II. Award Information 1](#award-information)

[1. Type of Award 1](#type-of-award)

[2. Summary of Funding 1](#summary-of-funding)

[Maximum Grant Support 1](#maximum-grant-support)

[III. Eligibility Information 1](#eligibility-information)

[1. Eligible Applicants 1](#eligible-applicants)

[2. Cost Sharing 1](#cost-sharing)

[3. Other 1](#other)

[IV. Application and Submission Information
1](#application-and-submission-information)

[1. Address To Request Application Package
1](#address-to-request-application-package)

[Application Materials 1](#application-materials)

[Application Preparation 1](#application-preparation)

[2. Content And Form Of Application Submission
1](#content-and-form-of-application-submission)

[Application Format Requirements 1](#application-format-requirements)

[Application Sequence 1](#application-sequence)

[Application Format 1](#application-format)

[3. Submission Dates and Times 1](#submission-dates-and-times)

[Letter of Interest 1](#__RefHeading___Toc143937373)

[Application Due Dates 1](#application-due-dates)

[Late Applications 1](#late-applications)

[4. Intergovernmental Review 1](#intergovernmental-review)

[5. Funding Restrictions 1](#funding-restrictions)

[6. Other Submission Requirements 1](#other-submission-requirements)

[V. Application Review Information 1](#application-review-information)

[1. Review Criteria 1](#__RefHeading___Toc143937380)

[2. Review and Selection Process 1](#review-and-selection-process)

[Funding Preferences 1](#funding-preferences)

[Other Awarding Factors 1](#other-awarding-factors)

[3. Anticipated Announcement and Award Dates
1](#anticipated-announcement-and-award-dates)

[VI. Award Administration Information
1](#award-administration-information)

[1. Award Notices 1](#award-notices)

[2. Administrative and National Policy Requirements
1](#administrative-and-national-policy-requirements)

[3. Reporting 1](#reporting)

[4. Performance Review 1](#d.-performance-review)

[VII. Agency and National Organization Contacts
1](#agency-and-national-organization-contacts)

[VIII. Other Information 1](#other-information)

[Technical Assistance Set-Aside 1](#technical-assistance-set-aside)

[Federal Tort Claims Act Coverage/Medical Malpractice Insurance
1](#federal-tort-claims-act-coveragemedical-malpractice-insurance)

[340b Drug Pricing Program 1](#b-drug-pricing-program)

[IX. Tips for Writing a Strong Application
1](#tips-for-writing-a-strong-application)

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

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

[Appendix C:](#appendix-c) [GUIDELINES FOR THE BUDGET PRESENTATION,
HEALTH CARE PLAN AND BUSINESS PLAN
1](#guidelines-for-the-budget-presentation-health-care-plan-and-business-plan)

[*GUIDELINES FOR COMPLETION OF THE BUDGET FORMS*
1](#guidelines-for-completion-of-the-budget-forms)

[*DEVELOPING THE HEALTH CARE PLAN AND BUSINESS PLAN*
1](#developing-the-health-care-plan-and-business-plan)

[Appendix D: Program Specific Forms
1](#appendix-d-program-specific-forms)

[FORM 1 -- Part A: GENERAL INFORMATION WORKSHEET - FY 2007
1](#form-1-part-a-general-information-worksheet---fy-2007)

[FORM 1 -- Part B: FUNDING REQUEST SUMMARY
1](#form-1-part-b-funding-request-summary)

[FORM 2: PROPOSED STAFF PROFILE 1](#form-2-proposed-staff-profile)

[FORM 3: INCOME ANALYSIS FORMAT 1](#form-3-income-analysis-format)

[FORM 4: COMMUNITY CHARACTERISTICS 1](#form-4-community-characteristics)

[FORM 5 -- Part A: SERVICES PROVIDED
1](#form-5-part-a-services-provided)

[FORM 5 -- Part B: SERVICE SITES \*\* 1](#form-5-part-b-service-sites)

[FORM 5 - Part C: OTHER ACTIVITIES/LOCATIONS
1](#form-5---part-c-other-activitieslocations)

[FORM 6 -- Part A: CURRENT BOARD MEMBER CHARACTERISTICS
1](#form-6-part-a-current-board-member-characteristics)

[FORM 6 -- Part B: REQUEST FOR WAIVER OF GOVERNANCE REQUIREMENTS
1](#form-6-part-b-request-for-waiver-of-governance-requirements)

[FORM 7: COMPLIANCE CHECKLIST
1](#form-7-compliance-checklist-page-1-of-2)

[FORM 8 - Part A: HEALTH CENTER AFFILIATION CERTIFICATION
1](#form-8--part-a-health-center-affiliation-certification)

[FORM 8 -- Part B: HEALTH CENTER AFFILIATION CHECKLIST
1](#form-8-part-b-health-center-affiliation-checklist)

[FORM 9 -- Part A: NEED FOR ASSISTANCE WORKSHEET CRITERIA
1](#form-9-part-a-need-for-assistance-worksheet-criteria)

[FORM 9 -- Part B: NEED FOR ASSISTANCE WORKSHEET -- FY 2007
1](#form-9-part-b-need-for-assistance-worksheet-fy-2007)

[Appendix e: Primary Care Association, Primary Care Office, And National
Organization Contacts
1](#appendix-e-primary-care-association-primary-care-office-and-national-organization-contacts)

[I. PRIMARY CARE ASSOCIATIONS 1](#i.-primary-care-associations)

[II. PRIMARY CARE OFFICES 1](#ii.-primary-care-offices)

[III. NATIONAL ORGANIZATIONS 1](#iii.-national-organizations)

[Appendix F: Definitions For New Access Point Applications
1](#appendix-f-definitions-for-new-access-point-applications)

# Funding Opportunity Description and General Information

## Purpose {#purpose .unnumbered}

President Bush's fiscal year (FY) 2007 budget proposes an increase of
\$181 million in the appropriation for the Consolidated Health Center
Program authorized under section 330 of the Public Health Service (PHS)
Act (42 U.S.C. 254b), as amended. Even though action on the FY 2007
appropriation has not been completed, the Health Resources and Services
Administration (HRSA) anticipates being able to accept applications from
organizations seeking a grant for operational support under the
Consolidated Health Center Program for a new access point(s). The
President's proposed FY 2007 budget includes funding to complete the
final year of the President's multi-year plan to serve millions of
additional people in the Nation's neediest communities.

President Bush's Health Centers Initiative, which began in FY 2002, will
increase health care access to 1,200 of the Nation's neediest
communities through new and/or significantly expanded health center
access points. One way to achieve this goal is through the creation of
new access points for the provision of comprehensive primary and
preventive health care services in areas of high need that will improve
the health status and decrease health disparities of the medically
underserved populations to be served. These new access points will
address the unique and significant barriers to affordable and accessible
health care services for the specific population and/or community
targeted by the application.

In FY 2007, HRSA will accept new access point applications for all types
of health centers supported under the Consolidated Health Center Program
including:

Community Health Centers (CHC) - section 330(e)

Migrant Health Centers (MHC) - section 330(g)

Health Care for the Homeless (HCH) - section 330(h)

> Public Housing Primary Care (PHPC) - section 330(i)

For the purposes of this document, the term "health center" refers to
the diverse types of health centers (i.e., CHC, MHC, HCH, and PHPC) that
are supported under section 330 of the PHS Act.

The Consolidated 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. New access points will provide comprehensive
primary and preventive health care services that will improve the health
status and decrease health disparities of the medically underserved
populations to be served. These new access points will address the
unique and significant barriers to affordable and accessible health care
services for the specific population and/or community targeted by the
application. Every new access point application is expected to
demonstrate compliance with the applicable requirements of section 330
of the PHS Act, the implementing regulations and HRSA Program
Expectations.

Overall for FY 2007, HRSA will support new health center access point
applications that demonstrate a high level of need in their community,
present a sound proposal to meet this need, and show that they are ready
to rapidly implement this proposal. In addition, the competitive nature
of the health care environment demands that primary care providers be
part of community-based delivery systems; therefore, HRSA will support
those health centers that can demonstrate responsiveness to their health
care environment and that have established collaborative and coordinated
delivery systems for the provision of health care to the underserved in
their communities.

## Background {#background .unnumbered}

The mission of HRSA is "to increase access to comprehensive primary and
preventive health care and to improve the health status of underserved
and vulnerable populations." All of the programs administered by HRSA
are focused on ensuring the availability and accessibility of essential
primary and preventive health services to the people who have the most
limited access to services and face the greatest barriers to care. HRSA
is committed to the goal of improving and expanding access to health
care for all Americans nationwide, and most importantly for the
estimated 45 million uninsured people in the United States who do not
have adequate access to affordable, appropriate primary and preventive
health care. More than 50 million people live in federally designated
medically underserved areas and lack access to a private primary care
provider.

Individually, each health center plays an important role in this plan
and combined they have had a critical impact on the health care status
of underserved and vulnerable populations throughout the United States
(U.S.). At the end of the calendar year 2005, 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 13 million medically underserved and
uninsured patients receive high quality, cost-effective, culturally
appropriate, accessible and affordable preventive and primary health
care services through the federally-funded health centers.

## Expected Results {#expected-results .unnumbered}

To assist organizations in their consideration of a new access point
application, HRSA has identified several critical areas that should be
examined prior to developing an application.

Competitive applicants will **demonstrate compliance**, with all
requirements of section 330 of the PHS Act, the programs' implementing
regulations (42 CFR 51c.301-404), and HRSA guidelines, including the
Health Center Program Expectations, at the time of application. In order
to confirm compliance, applicants are required to submit a completed
Compliance Checklist (see Form 7, page
[111](#form-7-compliance-checklist-page-1-of-2)) that has been certified
as accurate by the Chairperson of the Board of Directors.

All competitive organizations must demonstrate that the proposed new
access point(s) will serve populations in areas with the **greatest need
for services**. All applicants must submit a completed Need for
Assistance Worksheet (see Form 9 -- Part B, page
[122](#form-9-part-b-need-for-assistance-worksheet-fy-2007)) as part of
the application to demonstrate the relative need for additional primary
health care services in their proposed service area. Applicants are
encouraged to self-score the need for assistance worksheet (see Form 9
-- Part A, page
[116](#form-9-part-a-need-for-assistance-worksheet-criteria), for the
basis for scoring the worksheet) and to submit the completed worksheet
as part of a Letter of Interest (see Section IV, page
[32](#_Ref76194896)) prior to submitting an application. Only those
applications that score 70 or higher on the need for assistance
component of the application will have the merits of the application
evaluated by an Independent Review Committee (see Review and Selection
Process section, page [46](#review-and-selection-process)).

Competitive new access point applicants will demonstrate how the
proposed project will **increase access** to primary health care
services and reduce health disparities in the community/population to be
served. A competitive application will also demonstrate the extent to
which the receipt of the section 330 grant will increase access to care
in terms of the number of people to be served and the number of primary
care providers to be made available to the population. Competitive
applicants will further detail the current level of services available
to the community and how, with the additional Federal support being
requested, the organization proposes to develop a system of care which
increases access to care, services and available primary care providers
to the target population. New access point applicants must demonstrate
their efforts to achieve the goals of **Healthy People 2010** as part of
their efforts to increase access and reduce health disparities.
(Information on [Healthy People 2010]{.underline} is available at:
www.health.gov/healthypeople/.)

The competitive nature of the health care environment demands that
primary care providers be part of community-based delivery systems;
therefore, competitive applications will demonstrate responsiveness to
their health care environment and that they have developed
**collaborative and coordinated delivery systems** for the provision of
health care to the underserved in their communities. Successful
applications will demonstrate that they have coordinated and integrated
with the activities of other federally qualified health centers and
section 330 grantees, State and local health services delivery projects
and programs serving the same population(s) including any actual or
proposed partnerships and collaborative activities.

Competitive applicants will **present a sound and complete plan** for
the successful establishment of a new access point(s). This plan should
demonstrate responsiveness to the identified health care needs of the
target population, appropriate short- and long-term strategic planning,
coordination with other providers of care, organizational capability to
manage the proposed project, and cost-effectiveness in addressing the
health care needs of the target population. Competitive applicants will
respond thoroughly to the review criteria presented in Section V (see
page [36](#_Ref81215707)) of this guidance in the presentation of their
proposed new access point project.

Competitive applicants will present **a reasonable and accurate 3-year
budget** based on the activities proposed in the project plan.
Competitive applicants will present a budget for the new access point(s)
and request Federal funds that are reasonable and appropriate based on
the scope of the services to be provided and the number of new
individuals to be served. The budget should be consistent with the
health care and business plans presented in the application. Approved
Federal funding levels will be reviewed and may be adjusted based on
performance and an analysis of actual experience related to operating
costs, utilization, provider staffing and revenue generation. Applicants
are encouraged to carefully review Section IV and Appendix C of this
document for further clarification and instructions on the presentation
of the budget for new access point grant applications.

HRSA has placed an emphasis on the **readiness** of an applicant to
initiate the proposed project plan. HRSA expects an organization to
apply for section 330 new access point funding when it can demonstrate
that the **new access point(s) will be operational and providing
services in the community within 120-days of a grant award**.
Competitive applicants will demonstrate at a minimum, that within
120-days of a grant award, (1) a facility will be operational and ready
to begin providing services for the proposed population/community and
(2) providers will be available to serve at the new access point. HRSA
may consider on a case-by-case basis, a request to extend for good cause
the expected start up time to 180 days for a new access point to become
operational. It is expected that **full operational capacity will be
achieved within 2 years** of receiving Federal section 330 support and
that the third year of funding will represent the project at full
operational capacity for a 12-month period of time.

Applicants are encouraged to collaborate with the appropriate Primary
Care Associations, Primary Care Offices and/or National Organizations
(PCAs/PCOs/NOs -- see Appendix E, page
[126](#primary-care-association-primary-care-office)) in determining
their readiness to develop an application for a new access point.

## Specific Requirements/Expectations {#specific-requirementsexpectations .unnumbered}

As stated above, all applicants are expected to demonstrate compliance
with the applicable requirements of section 330 of the PHS Act,
implementing regulations, and HRSA guidelines, including the Health
Center Program Expectations (PIN 98-23 available at
www.bphc.hrsa.gov/pinspals/pinsarchive.htm). Applicants seeking funds to
support a new access point(s) are also expected to demonstrate
compliance with the implementing regulations (42 CFR Part 51c), as
applicable.

Specifically, a new access point is a new service site (see Appendix F,
Definitions, page [145](#definitions-for-new-access-point-applications))
for the provision of comprehensive primary and preventive health care
services. The two types of new access points referenced in this
application guidance are (1) new starts and (2) satellites (see Appendix
F, Definitions, page
[145](#definitions-for-new-access-point-applications)). Every new access
point application is expected to demonstrate compliance with the
applicable requirements of section 330 of the PHS Act, the implementing
regulations and HRSA Program Expectations.

All new access point applications are expected to:

a.  demonstrate that all persons will have ready access to the full
    range of required primary, preventive, enabling and supplemental
    medical health care services, such as oral health care, mental
    health care and substance abuse services, either directly on-site or
    through established arrangements without regard to ability to pay
    (see Appendix F, Definitions, page
    [145](#definitions-for-new-access-point-applications));

b.  demonstrate compliance at the time of application (or a plan for
    compliance within 120 days of a grant award) with the requirements
    of section 330, its guidelines and applicable regulations;

c.  demonstrate how section 330 funds will expand services and increase
    the number of people served through the establishment of a new
    service delivery site(s) and/or at an existing site(s) not currently
    within a section 330, HRSA funded scope of project;

d.  demonstrate that the site(s) will be operational and services will
    be initiated within 120 days of a grant award;

e.  demonstrate appropriate collaboration, coordination and integration
    with the activities of other federally qualified health centers and
    section 330 grantees, State and local health services delivery
    projects and programs providing services to the identified
    underserved population/community; and

f.  demonstrate how section 330 funds will augment already available
    funds and in-kind resources to expand existing primary health care
    service capacity to currently underserved populations.

New access points are expected to provide access to services at
locations and times that are most appropriate to address the most
significant barriers to care, gaps in services, significant health
disparities and the major health care problems of the target
population/community to be served. Applicants proposing to use **mobile
medical vans** for the delivery of primary care services may do so as a
new access point only if (1) it is a new mobile medical van added to an
existing fleet or is a new addition for a program that previously did
not have a mobile medical van in its approved scope of project;
[and]{.underline} (2) the van serves one or more new locations, operates
on a regular, fixed schedule, and provides primary care through the use
of clinicians who exercise independent judgment and generate clinical
encounters. Proposals to expand the operations of an existing mobile van
(e.g., add new providers or services, expand hours of operation at
current locations, etc.) are [NOT]{.underline} eligible for
consideration under NAP funding.

In addition to these general requirements, there are specific
requirements and expectations for applicants requesting funding under
each type of health center authorized under section 330. Applicants
requesting funding to support one or more health center types are
expected to demonstrate compliance in the application with the specific
guidelines, expectations and requirements, as applicable. Failure to
document and demonstrate compliance in the application will
significantly reduce the likelihood of approval and funding.

COMMUNITY HEALTH CENTER (CHC) APPLICANTS (section 330(e)):

Competitive CHC applicants will demonstrate that the new access point(s)
will increase access to comprehensive primary and preventive health care
and improve the health status of underserved and vulnerable populations
in the area to be served. Competitive applicants will also demonstrate
that the proposed new access point(s) will address the major health care
needs of the target population and will assure the availability and
accessibility of essential primary and preventive health services,
including oral health and 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 HRSA guidelines.

MIGRANT HEALTH CENTER (MHC) APPLICANTS (section 330(g)):

Competitive MHC applicants will demonstrate how the new access point(s)
will increase access to comprehensive and preventive health care
services and improve the health status of migrant and seasonal
farmworkers and their families (MSFWs) in the area to be served. MHC
applicants must also demonstrate that the proposed new access point(s)
will address the special needs of MSFWs and their families and will
assure the availability and accessibility of essential primary and
preventive health services, including oral health and mental health and
substance abuse services, to MSFWs. In addition, competitive applicants
will address the special environmental health concerns that are
associated with MSFWs. Applicants are expected to demonstrate compliance
with section 330(e), if applicable, and 330(g), and all applicable
regulations and HRSA guidelines.

Competitive MHC applicants will describe 1) the manner in which
comprehensive outreach is to be conducted and integrated into the
primary care delivery system, 2) how transportation and other enabling
services will be provided, 3) the manner in which case management and
eligibility assistance will be made available to MSFWs and 4) how
adjustments will be made for service delivery during peak and off-season
cycles.

Competitive MHC applicants will include information about how the health
center governance requirements are being/will be addressed.
Organizations that are *only* requesting support for a MHC, HCH and/or
PHPC and are requesting a waiver for one of the governance requirements
must complete and submit Form 6 -- Part B (see page
[110](#form-6-part-b-request-for-waiver-of-governance-requirements)) and
submit a waiver request that is in compliance with guidelines described
in PIN 98-12 with the application. The waiver request should include the
description of the reasons for the waiver and a detailed plan regarding
how the health center will comply with the intent of the statute.
Requests for waivers will not be granted to applicants that are also
approved for CHC funding.

HEALTH CARE FOR THE HOMELESS (HCH) APPLICANTS (section 330(h)):

Competitive HCH applicants will demonstrate that the new access point(s)
will increase access to comprehensive primary and preventive health care
and improve the health status of underserved homeless people in the area
to be served. Competitive HCH applicants will also demonstrate that the
new access point(s) will address the major health care needs of the
homeless population and will assure the availability and accessibility
of essential primary and preventive health services, including oral
health and mental health and substance abuse services, to homeless
persons. Applicants are expected to demonstrate compliance with section
330(e) and 330(h), and HRSA guidelines.

HCH applicants must also 1) indicate the mechanism for delivering
substance abuse services to homeless patients, 2) describe the manner in
which comprehensive outreach is to be conducted and integrated into the
primary care delivery system, 3) describe how transportation and other
enabling services will be provided, and 4) describe the manner in which
case management, eligibility assistance, and access to housing services
will be made available to homeless patients.

Competitive HCH applicants will include information about how the health
center governance requirements are being/will be addressed.
Organizations that are *only* requesting support for a MHC, HCH and/or
PHPC and are requesting a waiver for one of the governance requirements
must complete and submit Form 6 -- Part B (see page
[110](#form-6-part-b-request-for-waiver-of-governance-requirements)) and
submit a waiver request that is in compliance with guidelines described
in PIN 98-12 with the application. The waiver request should include the
description of the reasons for the waiver and a detailed plan regarding
how the health center will comply with the intent of the statute.
Requests for waivers will not be granted to applicants that are also
approved for CHC funding.

PUBLIC HOUSING PRIMARY CARE (PHPC) APPLICANTS (section 330(i)):

Competitive PHPC applicants will demonstrate that the new access
point(s) will increase access to comprehensive primary and preventive
health care and improve the health status of underserved public housing
residents in the area to be served. Competitive PHPC applicants will
also demonstrate that the new access point(s) will address the major
health care needs of the public housing residents and will assure the
availability and accessibility of essential primary and preventive
health services, including oral health and mental health and substance
abuse services, to public housing residents. PHPC applicants must also
describe the mechanism for involving residents in the preparation of the
application and in the on-going management of the program. Applicants
are expected to demonstrate compliance with section 330(e) and 330(i),
and HRSA guidelines.

Competitive PHPC applicants will include information about how the
health center governance requirements are being/will be addressed.
Organizations that are *only* requesting support for a MHC, HCH and/or
PHPC and are requesting a waiver for one of the governance requirements
must complete and submit Form 6 -- Part B (see page
[110](#form-6-part-b-request-for-waiver-of-governance-requirements)) and
submit a waiver request that is in compliance with guidelines described
in PIN 98-12 with the application. The waiver request should include the
description of the reasons for the waiver and a detailed plan regarding
how the health center will comply with the intent of the statute.
Requests for waivers will not be granted to applicants that are also
approved for CHC funding.

# Award Information

## 1. Type of Award {#type-of-award .unnumbered}

New access point grant awards are to support a new full-time[^1] service
delivery site(s) (see Appendix F, Definitions, page
[145](#definitions-for-new-access-point-applications)) for the provision
of comprehensive primary and preventive health care services to
underserved communities and populations. Every new access point is
expected to demonstrate compliance with the applicable requirements of
section 330 of the PHS Act, the applicable implementing regulations and
HRSA Program Expectations.

Applicants may submit a request for Federal support to establish a
single new access point or multiple access points in a single new access
point application. In addition, an applicant may request funding to
support one or multiple types of health centers (i.e., CHC, MHC, HCH,
PHPC) based on the population(s) to be served within a single
application (i.e., an applicant proposing to serve both the general
community and migrant and seasonal farmworkers can submit an application
requesting support under both the CHC and MHC programs). **Applicants
should indicate on Form 1 -- Part A (see page [Error: Reference source
not found](#_Ref76195506)) and Form 1 -- Part B (see page
[96](#form-1-part-b-funding-request-summary)) their request for funding
under the specific section 330 programs.**

Applications may be submitted for consideration from new organizations
(new start applicants) or existing grantees (satellite applicants). A
**NEW START** applicant is an organization that currently **DOES NOT
RECEIVE** any Federal grant support under the Consolidated Health Center
Program authorized under section 330 of the PHS Act. A new start
application should address the entire scope of the project (see Appendix
F, Definitions, page
[145](#definitions-for-new-access-point-applications)) being proposed
for Federal support. New start applicants may submit an application for
Federal support for a single site or a multi-site operation. New start
applicants may also request funding for one or multiple types of health
centers authorized under section 330 based on the specific type of
health center(s) (i.e., CHC, MHC, HCH, PHPC) for which new access point
funding is requested.

A **SATELLITE** applicant is an organization that **CURRENTLY RECEIVES**
grant support under the Consolidated Health Center Program authorized
under section 330 of the PHS Act. All satellite applicants must propose
to establish a new access point(s) to serve a new patient population
that is outside the applicant's approved scope of project (i.e., not
listed on the applicant's most recently submitted Exhibit B "Service
Sites" from the continuation application or Change in Scope request
under any section 330 program). A satellite new access point application
should address **ONLY** the service area and target population of the
proposed new access point(s) (i.e., only the new site(s) and service
area proposed in the satellite application, not all of the sites or the
entire service area of the applicant) in terms of need, population to be
served and the new delivery system being proposed. Satellite applicants
may submit an application for Federal support to establish a single new
access point or multiple access points (outside of their approved scope
of project under any section 330 program. Satellite applicants may also
request funding for one or multiple types of health centers authorized
under section 330 based on the specific type of health center(s) (i.e.,
CHC, MHC, HCH, PHPC) for which new access point funding is requested.
Satellite applicants **may not** request funding to support the
expansion/addition of services/programs/staff at a site(s) that is
currently listed as being a part of their approved scope of project
under the Consolidated Health Center Program.

## 2. Summary of Funding {#summary-of-funding .unnumbered}

President Bush's fiscal year (FY) 2007 budget proposes an increase of
\$181 million in the appropriation for the Consolidated Health Center
Program authorized under section 330 of the PHS Act. Note that
Congressional action on the FY 2007 appropriation has not been
completed. However, HRSA anticipates that approximately \$61 million
will be available to support approximately 102 new access point grant
awards in FY 2007.

## Maximum Grant Support {#maximum-grant-support .unnumbered}

The HRSA has established an annual **cap of \$650,000 for section 330
support** of new access points. The cap is the **maximum amount of
section 330 funding** that can be requested annually in a new access
point grant application in FY 2007 regardless of the number and/or type
of new access points to be supported and/or populations to be served
through the application. Not all applicants approved and funded will
receive that amount.

**Applicants may request Federal section 330 grant support up to
\$150,000 in Year 1 only for one-time minor capital costs for equipment
and/or alteration/renovation (see Appendix F, page
[145](#definitions-for-new-access-point-applications), for a
definition); however, the total request for section 330 support MUST NOT
exceed the established annual cap of \$650,000 in Year 1, Year 2 or Year
3. Applications that present a request for support in excess of the
established annual cap in either Year 1, Year 2 or Year 3 are considered
ineligible for review and will be returned without further
consideration.**

It is expected that the request for Federal support and the budgets
presented in the application will be reasonable and appropriate based on
the scope of the services to be provided and the number and type (i.e.,
homeless, migrant, public housing residents) of individuals to be served
(see Form 1 -- Part A, page [Error: Reference source not
found](#_Ref76195506)). The budget should also be consistent with the
health care and business plans presented in the application. The
following figures are provided as a guideline in developing the Federal
budget request: \$150 Federal grant dollars per general community user,
\$200 Federal grant dollars per migrant/seasonal farmworker user, \$200
Federal grant dollars per homeless user; and \$200 Federal grant dollars
per public housing user. **If the actual anticipated Federal grant
dollar per user cost will significantly exceed the benchmarks provided,
applicants should include a justification as part of the budget
narrative.** See Section IV of this document for further guidance on
completing the budget presentation.

Federal funding levels will be reviewed prior to a final funding
decision and may be adjusted based on the organization's past
performance and an analysis of experience related to operating costs,
utilization, provider staffing and revenue generation. Federal funding
levels for new start applicants may also be adjusted based on analysis
of the budget and cost factors. See Section IV and Appendix C of this
application guidance for further information and instruction on the
development of the application budget.

# Eligibility Information

## 1. Eligible Applicants {#eligible-applicants .unnumbered}

Public or private nonprofit entities, including tribal, faith-based and
community-based organizations, may apply for a grant for operational
support of a new access point(s) under the Consolidated Health Center
Programs authorized under section 330 of the PHS Act. Applicants are
expected to demonstrate compliance with the requirements for the
specific type of health center(s) (i.e., CHC, MHC, HCH, and PHPC) for
which funding is requested.

An application submitted under announcement number HRSA-07-067 will be
considered eligible if it meets all of the applicable eligibility
requirements listed below. Applications that do not meet these
eligibility requirements will not be accepted and will be returned
without further consideration.

1.  *All Applicants:* Applicant is a public or private, nonprofit
    entity, including tribal, faith-based, and community-based
    organizations.

2.  *All Applicants:* Only one application is submitted for
    consideration under HRSA-07-067 'New Access Points.' in FY 2007. If
    more than one new access point application is submitted for
    consideration under HRSA 07-067 in FY 2007, HRSA will accept the
    first application received for review, and will return all
    subsequent applications from the same organization without further
    consideration.

3.  *All Applicants:* Application proposes to serve a defined geographic
    area that is federally-designated, in whole or in part, as a
    Medically Underserved Area (MUA) or a Medically Underserved
    Population (MUP). \[If the area is not currently
    federally-designated, in whole or in part as a MUA or MUP, the
    applicant must provide documentation that the request has been
    submitted in order for timely processing prior to a final HRSA
    funding decision on the FY 2007 New Access Point application\].
    *NOTE: If the applicant is requesting funding only for MHC, HCH
    and/or PHPC, the applicant does not need to have a MUA/MUP
    designation for the proposed service area and/or target population.*

4.  *All Applicants:* Application requests section 330 funds to
    establish a new access point(s) for the provision of required
    comprehensive primary, preventive, enabling and supplemental health
    care services (see definition in Appendix F, page
    [145](#definitions-for-new-access-point-applications)) including
    oral health care, mental health care and substance abuse services,
    either directly on-site or through established arrangements without
    regard to ability to pay (e.g., applicant does not propose a new
    access point(s) to provide a single service, such as dental, mental
    health or prenatal services).

5.  *All Applicants:* Application proposes access to services for all
    individuals in the targeted service area or population. In other
    words, applicant does not propose a new access point(s) to
    exclusively serve a single age group (e.g., children) or lifecycle
    (e.g., geriatric only). In instances where a sub-population is being
    targeted within the service area or population (e.g., homeless
    children and adolescents or children in schools), the applicant must
    demonstrate how health care services will be made available to other
    persons in need of care who may seek services at the proposed sites.

6.  *All Applicants:* Application requests annual Federal section 330
    funding in Year 1, Year 2, or Year 3 that, as presented on PHS Form
    5161-1: SF 424A and Form 1-B, DOES NOT exceed the established cap of
    \$650,000 on annual Federal funding available for section 330 new
    access points.

7.  *All Applicants:* Application must adhere to the 200-page limit on
    the length of the application when printed by HRSA. The page limit
    includes the narrative proposal, budget presentation, program
    specific forms, documents, and other attachments detailed on
    p.[18](#sf-424-non-construction-table-of-contents) of this
    guidance).

> Note: The page limit does NOT include the Tables of Contents or the
> PHS 5161-1 Standard Forms (i.e., SF 424 Face Page, SF 424a Budget for
> Non-Construction Programs, HHS Checklist, or Disclosure of Lobbying
> Activities).

8.  *Satellite Applicants Only:* Applicant proposes to establish a new
    delivery site (e.g., the applicant does not (a) propose funding to
    support the relocation of a site(s), and/or (b) propose the
    expansion of capacity (additional providers, new services, new
    populations, etc.), at any site(s) already in their approved scope
    of project (i.e., a site listed on the applicant's most recently
    approved Form 5-Part B/Exhibit B "Service Sites") under any section
    330 program.).

## 2. Cost Sharing {#cost-sharing .unnumbered}

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 the budget and budget justification section of this document
(see Section IV and Appendix C) for clarification and guidelines
pertaining to the presentation of the budget.

## 3. Other {#other .unnumbered}

Applications that exceed the ceiling amount of \$650,000 will be
considered non-responsive and will not be considered for funding under
this announcement.

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

# Application and Submission Information

## 1. Address To Request Application Package {#address-to-request-application-package .unnumbered}

### Application Materials {#application-materials .unnumbered}

The application and submission process has changed significantly. HRSA
is requiring applicants for this funding opportunity to apply
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. Grantees must request an exemption in writing from
<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 you are seeking
funding for. As indicated in this guidance, HRSA and its Grants
Application Center (GAC) will only accept paper applications from
applicants that received prior written approval.

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. The required PHS 5161-1 Forms are now provided
through the Grants.gov application package link. For reference, these
forms and instructions may also be obtained from the following sites by:

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

Or

\(2\) 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.

### Application Preparation {#application-preparation .unnumbered}

Applicants are encouraged to thoroughly review the documents referenced
above prior to finalizing a decision to apply and/or preparing an
application for submission. In developing applications, applicants are
encouraged to work with the appropriate PCA, PCO and/or NO (See Appendix
E, page [126](#primary-care-association-primary-care-office)) and to use
feedback provided through the Letter of Interest (LOI) process to
prepare high quality, competitive applications (see page
[32](#_Ref76196040), for further information about completing a LOI).
**Applicants should provide all required information in the sequence and
format described in the instructions.** Information and data should be
accurate and consistent and directions and written instructions should
be followed carefully and completely. **Applications not meeting
application requirements may be returned without processing or may
result in a low rating by the Objective Review Committee (ORC).**

**Only those materials/documents included with the application submitted
by the announced deadline will be considered**. Supplemental
materials/documents submitted after the application deadline will not be
included for consideration. Documents such as letters of support should
be submitted as part of the application. Letters of support sent
directly to DHHS, HRSA, or Bureau of Primary Health Care (BPHC)
administrators or sent after the application deadline will not be added
to an application.

The entire application guidance and related materials should be reviewed
thoroughly prior to making a decision to apply for operational support
of a new access point(s). **All applicants requesting funds to support a
new access point under section 330 of the PHS act must use PHS Form
5161-1 in conjunction with the forms and materials in this application
guidance.** The PHS 5161-1 forms contain additional general information
and instructions for grant applications, proposal narratives, and
budgets as prescribed by the Office of Management and Budget, therefore,
that information is not repeated in this document. Instructions for
preparing portions of the application that must accompany PHS Form
5161-1 appear in the "Application Format" section below.

It is recommended that applicants also thoroughly review the following
reference documents:

-   Health Care Safety Net Amendments of 2002, Public Law 107-251
    (section 330 of the PHS Act as amended)

-   PIN 98-12, **"**Implementation of the Section 330 Governance
    Requirements" (signed April 28, 1998)

```{=html}
<!-- -->
```
-   PIN 98-23, "Health Center Program Expectations" (signed August 17,
    1998)

-   PIN 98-24, "Amendment to PIN 97-27 Regarding Affiliation Agreements
    of Community and Migrant Health Centers" (signed August 17, 1998)

-   PIN 97-27, "Affiliation Agreements of Community and Migrant Health
    Centers" (signed July 22, 1997)

-   PAL 2002-09, "President's Initiative to Expand Health Centers"
    (signed May 16, 2002)

These documents and any others referenced in this grant application kit
are available on the HRSA web page: http://www.bphc.hrsa.gov/pinspals/.
PHS Form 5161-1 is available for downloading from
http://www.hrsa.gov/grants/forms.htm.

## 2. Content And Form Of Application Submission {#content-and-form-of-application-submission .unnumbered}

### Application Format Requirements {#application-format-requirements .unnumbered}

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
200 pages when printed by HRSA, approximately 20 MB.** **This 200-page
limit includes the abstract, project and budget narratives, program
specific forms 1-10, attachments, and letters of commitment and
support.** Standard forms (from the PHS 5161-1 packet) are NOT included
in the page limit.

**Applications that exceed the specified limits (approximately 20 MB, or
that exceed 200 pages when printed by HRSA) will be deemed
non-compliant. All non-compliant applications will be returned to the
applicant without further consideration.**

### Application Sequence {#application-sequence .unnumbered}

Applications for funding must consist of the following documents in the
following order:

### SF 424 Non Construction -- Table of Contents {#sf-424-non-construction-table-of-contents .unnumbered}

-   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 a
    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        **Form Type** **Instruction**          **HRSA/Program
  Application                                                Guidelines**
  Section**                                                  
  ------------------- ------------- ------------------------ --------------------
  Application for     Form          Pages 1, 2 & 3 of the    Not counted in the
  Federal Assistance                SF-424 face page,        page limit.
  (SF-424)                          includes uploaded        
                                    Project Abstract         

  Grants.gov Lobbying Form          Required Certification   Not counted in the
  Form                              Regarding Lobbying       page limit.

  Budget Narrative    Form /        Supports the upload      Attachment required
  Attachment Form     Attachment    (attachment) of Line     to the form.
                                    Item Budget and          **Includes Line Item
                                    Narrative Budget         Budget, and
                                    Justification document   Narrative Budget
                                                             Justification.**
                                                             Merge into a single
                                                             document. The
                                                             uploaded attachment
                                                             is counted in the
                                                             page limit. 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).

  Project Narrative   Form /        Supports the upload      Attachment required
  Attachment Form     Attachment    (attachment) of Project  to the form.
                                    Narrative document       **Includes Program
                                                             Narrative, Health
                                                             Care Plan and
                                                             Business Plan**.
                                                             Merge into a single
                                                             document. The
                                                             uploaded attachment
                                                             is counted in the
                                                             page limit. 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 Information  Form          Pages 1 & 2 budget for   Not counted in the
  for                               the request of Non       page limit.
  Non-Construction                  construction related     
  Programs (SF-424A)                funds                    

  HHS Checklist Form  Form          Pages 1 & 2 of the HHS   Not counted in the
  PHS-5161                          checklist.               page limit.

  Assurances for      Form          Supports assurances for  Not counted in the
  Non-Construction                  non construction         page limit.
  Programs (SF-424B)                programs                 

  Disclosure of       Form          Supports structured data Not counted in the
  Lobbying Activities               for lobbying activities, page limit.
  (SF-LLL)                          should be completed if   
                                    applicable               

  Attachments Form    Form /        Supports the upload      See following
                      Attachments   (attachment) of up to 15 attachment table for
                                    numbered attachments.    specific sequence
                                    This form only contains  and instructions.
                                    the attachment list      All uploaded
                                                             attachments ARE
                                                             counted in the page
                                                             limit. 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 attachment rows. Do not use the rows assigned to
    a specific purpose in the program guidance.

-   Merge similar documents into a single document. Where several pages
    are expected in the attachment, place a table of contents cover page
    specific to the attachment. Table of contents page will not be
    counted in the page limit.

  -----------------------------------------------------------------------
  **Attachment     **Attachment Description (Program Guidelines)**
  Number**         
  ---------------- ------------------------------------------------------
  Attachment 1     Program Specific Forms 1 through 10 (See section xi
                   below for detailed information)

  Attachment 2     Corporate Bylaws

  Attachment 3     Project Organizational Chart

  Attachment 4     Floor Plan

  Attachment 5     Service Area Map

  Attachment 6     Job or Position Descriptions AND Biographical Sketches
                   for Key Personnel

  Attachment 7     Co-Applicant Agreement (As applicable). If not
                   applicable, state this on one page and attach.

  Attachment 8     Sub-Recipient Documentation (As applicable). If not
                   applicable, state this on one page and attach.

  Attachment 9     Contracts, agreements, etc. (As applicable). If not
                   applicable, state this on one page and attach.

  Attachment 10    Most recent independent financial audit

  Attachment 11    Articles of Incorporation

  Attachment 12    Internal Revenue Service (IRS) Tax Exempt
                   Certification or W-9 Form

  Attachment 13    Letters of Support

  Attachment 14    Discount Sliding Fee Schedule

  Attachment 15    Other Relevant Documents (As applicable)
  -----------------------------------------------------------------------

[]{.mark}

### Application Format {#application-format .unnumbered}

The following provides additional instructions on completing the
application.

***i. Application Face Page***

Public Health Service (PHS) Application Form 5161-1, provided with the
application package. Prepare this page 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 5a. Federal Entity Identifier: Grants.gov Tracking number (to
    be filled out prior to mailing in signed face page. See Appendix A
    for more information)*

-   *Box 5b. Federal Award Identifier: 10-digit grant number (H80...)
    found in box 4b from the most recent NGA, if applicable.*

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

-   *Box 12 Funding Opportunity Number and Title: HRSA-07-067 and New
    Access Point Application, respectively.*

-   *Box 15 Descriptive Title of Applicant's Project: Project Abstract
    needs to be uploaded here.*

-   *Box 16 Congressional Districts: Upload any additional congressional
    districts as applicable for the HRSA grant. [Not]{.underline}
    counted in the page limit.*

**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](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.]{.underline}* 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/dunsccr.htm.  )

***ii. Table of Contents***

For electronic applications no table of contents is necessary as it will
be generated by HRSA. For applicants that have received an exemption
from electronic submission, the application should be presented in the
order of the Table of Contents provided earlier. (Note: the Table of
Contents will not be counted in the page limit).

***iii. Application Checklist***

PHS Form 5161-1 (Pages 25-26) provided with the application package.

***iv. Budget***

The SF424A: Budget Information-Non Construction Program is required by
HRSA's Division of Grants Management Operations as prescribed by OMB
Circular A-102. Using Application Form 5161-1 provided with the
application package, please complete Sections A, B, E, and F (if
applicable) of PHS Form 5161-1: Standard Form 424A for the first year of
the proposed project and then provide a line item budget (see below) for
each grant year using the budget categories in the SF 424A.

A complete budget presentation will include:

-   Form 1 -- Part B: Funding Request Summary;

-   PHS Form 5161-1: SF 424A, Sections A, B, E and F (if applicable);

-   Form 3: Income Analysis Worksheet for Year 1, Year 2, and Year 3 of
    the proposed project;

-   Line Item Budget for each 12-month period requested for Federal
    funding

-   Narrative Budget Justification summarizing the budget for the
    proposed project.

[Please review the 'Application Format' (page
[17](#application-format-requirements)for instructions on the order of
submission.]{.underline}

See instructions in Appendix C: Program Specific Forms with Instructions
for the Budget Presentation, Health Care Plan and Business Plan (page
[80](#appendix-c) of the guidance) for further instructions on
completing the Budget presentation.

Awards, on a competitive basis, will be for a one year budget period.
Applications for continuation grants funded under these awards beyond
the initial one-year budget period but within the approved new access
point 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 Government. Note: Project periods for
satellite applicants will be aligned with the existing project and new
starts will be awarded up to a 3-year project period.

***v. Line Item Budget and Narrative Budget Justification***

The budget details the amounts requested for each line of the PHS Form
5161-1/SF 424A and how each item will support achievement of the
proposed objectives for the entire span of the three year project
period. The narrative budget justification provides additional
information and detail to describe the line item budget.

*Line Item Budget*

Provide a detailed line-item budget that describes the amounts requested
for each category (e.g. personnel costs, indirect costs, travel, etc.)
to explain the costs entered in standard form 424A of the Public Health
Service (PHS) 5161-1. The budget period is for ONE year; however,
applicants must submit additional ONE year line item budgets for each of
the subsequent project period years (3 years TOTAL) at the time of
application. Expense information must include further detail by object
class. **A sample line item budget is available in Appendix C:
Instructions for the Budget Presentation, Health Care Plan and Business
Plan are provided on page [85](#sample-budget) as a broad outline.**

*Narrative Budget Justification*

The narrative budget justification summarizes the budget for the entire
project period and anticipated changes in budget items, projected costs
and revenues over the 3-year project period, potential changes in cost
of living, benefit packages, large purchases, etc*.* Applicants should
provide one narrative budget justification for **Years 1-3** that
describe how the categorical costs are derived and the necessity and
reasonableness of the proposed costs. The accompanying narrative budget
justification should specifically describe **how each item will support
the achievement of proposed goals/objectives** and methodologies (e.g.
cost of living increases, etc.) used to develop the identified costs.
The narrative budget justification MUST be concise. Do NOT use the
justification to expand the project narrative.

Budget justification narratives for the individual health center type
must be provided in sufficient detail to support one-step below the
object class category level, as described below. 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.

Be certain to include the following in the narrative Budget
Justification. Additional information and detail may be provided in
narrative form as needed.

[]{.mark}

*Personnel Costs: Personnel costs should be explained by listing each
staff member who will be supported from funds, name (if possible),
position title, percent full time equivalency, annual salary and wages,
and the exact amount requested for each project year which mainly covers
indirect cost. Please reference 'Form 2: Proposed Staff Profile' as
justification for the 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. In general, the
fringe benefits should be directly proportional to that portion of
personnel costs that are allocated for the project.*

*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.*

*Equipment: List equipment costs and provide justification for the need
of the equipment to carry out the program's goals. Extensive
justification and a detailed status of current equipment must be
provided when requesting funds for the purchase of computers and
furniture items.*

Applicants are limited to using no more than \$150,000 of the total
Federal funds requested (not to exceed \$650,000 in any year) to support
equipment and minor facility alteration/renovation in the first year of
the proposed project. *Only major (costing over \$5,000 per unit)
equipment items need to be itemized, with equipment costs and
justifications. Items costing less than \$5,000 should be aggregated
under supplies, with a brief explanation.*

*Supplies: List the items that the project will use. In this category,
separate office supplies from medical and educational 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, and explain how the amounts were developed
(e.g., medical supplies were based on 20,000 encounters at \$2 per
encounter to arrive at the \$40,000 appearing in the budget).*

*Contractual (Subcontracts): To the extent possible, all subcontract
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. Categorize substantive programmatic or
administrative contracts costs according to type (e.g., medical
referral, lab referral, management consultant) under 2 headings --
patient care and non-patient care by costs.*

*Construction (Alteration and Renovation): (See Appendix F, Definitions)
In general, Alteration and Renovation (A&R) is work required to change
the interior arrangements or other physical characteristics of an
existing facility or installed equipment so that it may be more
effectively utilized for its currently designated purpose or adapted to
an alternative use to meet a programmatic requirement. A&R costs that do
not constitute construction are allowable charges to PHS supported
projects and activities. Section 330 grant funds may not be used to
support construction of facilities.*

*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, organizational rent, utilities and insurance fall under this
category if they are not included in an approved indirect cost rate.
Consultant costs for technical assistance, legal fees, dues,
subscriptions, and audit related costs may also fall under this
category.*

*Indirect Costs: Only those organizations with a pre-approved federally
negotiated indirect cost rate should include an indirect cost rate in
the budget presentation. 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-21, 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.*

vi. ***Staffing Plan and Personnel Requirements***

Applicants must present a staffing plan and profile (Form 2: Staffing
Profile) for Year 1, Year 2, and Year 3 of the project which identifies
the total personnel and number of FTE staff to be supported by the new
access point funds. Provide a justification for the plan that includes
education and experience qualifications and rationale for the amount of
time being requested for each staff position within the narrative, as
needed. Position descriptions that include the roles, responsibilities,
and qualifications of proposed project staff must be included in
Attachment 6. Copies of biographical sketches for any key employed
personnel that will be assigned to work on the proposed project must
also be included in Attachment 6.

New Start applicants should include staff for the entire scope of the
project (i.e., total for all sites). Satellite applicants should include
a staffing profile for ONLY the new access point being proposed.

vii. ***Assurances***

This form and detailed instructions are available in PHS Application
Form 5161-1 provided with the application package.

viii. ***Certifications***

See Box 21 of the SF 424 Face Page and detailed instructions available
in the PHS Application Form 5161-1 provided with the application
package.

**ix. 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 information
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, the population group(s) to be served, and a summary of the
applicant organization.

**The project abstract must be single-spaced and limited to one page in
length.**

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 district(s) for the applicant organization and the
    project (if different)

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

-   Existing Federal funding received, if applicable

The Abstract narrative should include:

-   A brief history of the organization, the community to be served and
    the target population(s).

-   A summary of the major health care needs and barriers to care to be
    addressed by the proposed project.

-   A summary of the proposed project including numbers of providers,
    FTEs, delivery locations, services, and total number of users and
    encounters expected at full operational capacity (see Appendix F:
    Definitions, page
    [145](#definitions-for-new-access-point-applications)).

-   A brief description of any other relevant information.

***x. Program Narrative***

The program narrative should be **a detailed description of the
community/target population(s) to be served and the applicant
organization's plan for addressing the identified health care
needs/issues of the community/target population**. \[See Appendix F,
Definitions, page [145](#definitions-for-new-access-point-applications),
for a definition of target population and service area.\] In general,
this section includes a description of the health care needs of the
community/target population(s), the factors responsible for these needs,
community resources available to meet community health needs, the
planning process and community needs assessment that precipitated the
grant application, how the organization has/will integrate services with
other efforts in the community, the extent to which the applicant's
project plan addresses the specific program requirements (i.e.,
compliance), the organization's capacity to address the health needs and
experience in providing services, and the readiness of the applicant
organization to initiate the proposed project. The program narrative
should be consistent with the Health Care Plan and Business Plan
sections.

The program narrative for new start applicants should address the entire
scope of the new access point project being proposed for Federal
support. The program narrative for satellite applicants should address
**ONLY** the service area and target population of the proposed new
access point(s).

**The program narrative is expected to describe the new access point(s)
at full operational capacity and demonstrate how this will be achieved
over the first two years of the project**. For a definition of full
operational capacity and the appropriate ratios for calculating
operational capacity, refer to Appendix F, Definitions, page
[145](#definitions-for-new-access-point-applications) of this guidance.

All applicants should ensure that the program narrative completely
addresses the specific elements in the Review Criteria (pages
[36](#_Ref76196781)-[46](#review-and-selection-process)), including the
appropriate health center type-specific elements. 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 required/optional attachments. Attachments should not contain any
required narrative.

This following provides a framework for the program narrative. It should
be succinct, self-explanatory and well organized so that reviewers can
understand the proposed project. Program narrative should be organized
using the following section headers:

***Introduction***

The introduction is intended to be a **brief synopsis** of the
community/target population(s), the applicant organization, and the
scope of the proposed project. The applicant should summarize the need
for health services in the community and the organization's proposed
response to that need.

[]{.mark}

***NEED***

See Criterion 1: NEED in the Review Criteria Section (see page
[37](#_Ref81217154)) for the specific elements that should be addressed.

***response***

See Criterion 2: RESPONSE in the Review Criteria Section (see page
[38](#_Ref81217206)) for the specific elements that should be addressed.

***EVALUATIVE MEASURES***

See Criterion 3: EVALUATIVE MEASURES in the Review Criteria Section (see
page [42](#_Ref143938280)) for the specific elements that should be
addressed.

***impact***

See Criterion 4: IMPACT in the Review Criteria Section (see page
[42](#_Ref81217265)) for the specific elements that should be addressed.

***resources/capabilities***

See Criterion 5: RESOURCES/CAPABILITIES in the Review Criteria Section
(see page [43](#_Ref81217291)) for the specific elements that should be
addressed.

[]{.mark}

***support Requested***

See Criterion 6: SUPPORT REQUESTED in the Review Criteria Section (see
page [44](#_Ref81217320)) for the specific elements that should be
addressed.

***governance***

See Criterion 7: GOVERNANCE in the Review Criteria Section (see page
[44](#_Ref81217357)) for the specific elements that should be addressed.

Applicants are required, as appropriate, to provide a copy of the signed
bylaws demonstrating compliance with and reflecting all functions and
responsibilities cited in section 330 of the Public Health Service (PHS)
Act. *See PIN 98-12: Implementation of the 330 Governance Requirements
for additional information on section 330 governance requirements.*

***READINESS***

See Criterion 8: READINESS in the Review Criteria Section (see page
[46](#_Ref81217379)) for the specific elements that should be addressed.

**xi. Program Specific Forms**

Forms 1-10 should be included in the appropriate section of the
application, as detailed in the Application Sequence. Please refer to
Appendix D (page [93](#appendix-d-program-specific-forms)) of this
guidance for all program specific forms. The forms supply information in
a concise and consistent fashion. Please note that only the OMB forms,
approved by the U.S. Office of Management and Budget, should be
submitted with the grant application (included in this guidance
application packet). **Forms 1 -- 5, 6 -- Part A, 7, 9 -- Part B, and 10
are required for all applicants.** *Only applicants requesting a waiver
for governance requirements must submit Form 6 -- Part B. 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 --** see page
    [Error: Reference source not found](#_Ref76195506). Each applicant
    must complete the General Information Worksheet. This form provides
    a concise summary of information that is consistent with the budget,
    user and encounter projections presented in the project description,
    Health Care and Business Plans and other forms.

-   **FORM 1, Part B -- Funding Request Summary** -- see page
    [96](#form-1-part-b-funding-request-summary). Each applicant must
    complete the Funding Request Summary. This form identifies the
    amount of Federal funding being requested.

-   **FORM 2 -- Proposed Staff Profile** -- see page
    [97](#form-2-proposed-staff-profile). Each applicant must complete
    the Proposed Staff Profile. This form reports the total personnel
    supported with Federal funds for EACH YEAR 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 budget
    presentation.

-   **FORM 3 -- Income Analysis Format** - see page
    [[99]{.mark}](#form-3-income-analysis-format). Each applicant must
    complete the Income Analysis Format for Year 1, Year 2, AND Year 3.
    The form presents revenue information showing projections for
    patient service revenue and revenue by payment source. Anticipated
    changes within the proposed project period should be addressed in
    the budget presentation.

-   **FORM 4 -- Community Characteristics --** see page
    [101](#form-4-community-characteristics). Each applicant must
    complete the Community Characteristics. The form reports
    community-wide and target population data for the new access point
    for the most recent period for which data are available. New start
    applicants should include information on the entire scope of the
    proposed project and satellite applicants should address only the
    service area of the new site(s). Target population data should be a
    subset of the community-wide data and reflect the population the
    health center 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.

[]{.mark}

-   **FORM 5, Part A -- Services Provided** -- see page
    [102](#form-5-part-a-services-provided). Each applicant must
    complete Form 5-Part A: Services Provided. Applicants must identify
    what services will be available at the health center 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. New start applicants should include
    information on the entire proposed scope of the project and
    satellite applicants should address only the services of the new
    site(s).

-   **FORM 5, Part B -- Service Sites --** see page
    [104](#form-5-part-b-service-sites) \[See Appendix F, page
    [145](#definitions-for-new-access-point-applications), for a
    definition of service site.\] New start applicants should list all
    service sites to be included in the proposed scope of project.
    Satellite applicants should include both the proposed new access
    point(s) **in addition** to all current service sites listed on the
    most recent Form 5--Part B/Exhibit B "Service Sites" (from the most
    recently submitted Change of Scope, competing or non-competing
    continuation application).

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-   **FORM 5, Part C -- Other Activities/Locations (As applicable) --**
    see page [107](#form-5---part-c-other-activitieslocations). Please
    see this form's accompanying instructions and the definition of
    service site in Appendix F (page
    [145](#definitions-for-new-access-point-applications)) 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 and have therefore appeared on previously
    submitted Form 5 - Part B Service Site Forms. Although not
    considered sites as defined in Appendix F, these
    "activities/locations" should be documented in applications on Form
    5 - Part C to be considered part of the approved scope of project.

In general these types of services and locations can be generalized into
major categories, such as health fairs, immunization clinics, etc., that
do not have regular defined schedules and occur on an as needed basis.
(Service sites should be listed on Form 5--Part B. Please see definition
of service site in Appendix F (page
[145](#definitions-for-new-access-point-applications)) to determine
those activities or locations that should be listed on that Form.)

[]{.mark}

-   **FORM 6, Part A -- Board Member Characteristics** -- see page
    [109](#form-6-part-a-current-board-member-characteristics). Each
    applicant must complete the Board Member Characteristics. Applicants
    should list all current board members and provide relevant
    characteristics as requested.

[]{.mark}

-   **FORM 6, Part B -- Request for Waiver of Governance Requirements
    (as applicable)**: - see page
    [110](#form-6-part-b-request-for-waiver-of-governance-requirements).
    Health centers are eligible for a governance waiver if they are
    requesting/receiving HCH, PHPC, and/or MHC funding. Requests for
    waivers will not be granted to applicants that are also
    requesting/receiving CHC funding. If a waiver is requested,
    applicants should clearly identify which requirements are to be
    waived, and present alternative arrangements in lieu of the required
    elements. (See PIN 98-12 for additional information.)

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-   **FORM 7 -- Compliance Checklist** -- see page
    [111](#form-7-compliance-checklist-page-1-of-2). Each applicant must
    complete the Compliance Checklist. This form provides a checklist
    for assuring compliance with all section 330 requirements. Please
    sign and date the form prior to submission.

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-   **FORM 8 -- Part A: Health Center Affiliation Certification** -- see
    page [113](#form-8--part-a-health-center-affiliation-certification).
    Submission of Form 8 -- Part A is required for all CHC and/or MHC
    new access point applicants. Applicants should indicate if any of
    the identified affiliation arrangements are present in the proposed
    new access point application. If no such affiliations are proposed,
    the governing board chairperson should sign the certification and
    submit only FORM 8 -- Part A. If any of the affiliation arrangements
    are presented, applicants must also complete and submit FORM 8 --
    Part B.

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-   **FORM 8 -- Part B: Health Center Affiliation Checklist (As
    Applicable)** -- see page
    [114](#form-8-part-b-health-center-affiliation-checklist)

CHC and/or MHC applicants proposing affiliation arrangements identified
in FORM 8 -- Part A, must also submit a completed FORM 8 -- Part B. The
completed checklist will provide the HRSA information regarding any
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 the HRSA Program Expectations
for Health Centers and PINs 97-27 and 98-24. If the proposed affiliation
arrangement has not been previously approved, the applicant MUST ALSO
submit an application for approval as detailed in PIN 98-24 **Applicants
must submit all pertinent documents as part of the application for each
proposed affiliation.**

-   **FORM 9 -- Part B: Need For Assistance Worksheet** - see page
    [122](#form-9-part-b-need-for-assistance-worksheet-fy-2007). As part
    of the application, applicants must complete and submit the Need for
    Assistance Worksheet found in FORM 9 -- Part B. Applicants that
    score 70 or higher on Form 9 -- Part B will have the merits of the
    application evaluated by reviewers using published review
    criteria*.*

-   **FORM 10 -- Annual Emergency Preparedness and Management (EPM)
    Report** -- see page
    [123](#form-10-annual-emergency-preparedness-and-management-epm-report).
    Each applicant must complete the Annual Emergency and Management
    Report. This form will be used to assess the emergency preparedness
    of health centers and assist HRSA in determining technical
    assistance training and resource needs.

***xii. 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)  []{#_Ref143938736 .anchor}**Attachment 1: Program Specific Forms 1
    -- 10**

All forms and attachments are expected to reflect the scope of the
application submitted as appropriate. Therefore, new start applicants
should include information on the entire scope of the proposed project
and satellite applicants should address only the service area of the new
site(s) (i.e., only the new area proposed under the satellite, not the
entire service area of the applicant). **Please review the Forms Section
above to determine the required forms.**

Please refer to Appendix D to download the OMB approved program specific
forms to be submitted with the application. Reference above for a
description of program specific forms to be included as part of the
application submission.

2)  **Attachment 2: Corporate Bylaws, Signed and Dated**

Applicants must include a complete copy of the applicant organization's
corporate bylaws that are signed and dated by the appropriate individual
indicating review and approval by the Board of Directors.

3)  **Attachment 3: Project Organizational Chart**

Applicant should provide a one-page figure that depicts the
organizational structure including the governing board, key personnel,
staffing, subcontractors and collaborating organizations.

4)  **Attachment 4: Floor Plan**

Applicant should provide a one-page floor plan of the proposed new
access point delivery site, including proposed exam rooms, waiting area,
etc.

5)  **Attachment 5: Service Area Map**

Applicants must include a map of the service area under the
organization's scope of project and the organization's point(s) of
service (i.e., service sites listed in Form 5 - Part B) within the area.
The map should also include other FQHCs, FQHC Look-Alikes,
subcontractors, and collaborating service organizations indicating
medically underserved areas (MUAs), medically underserved populations
(MUPs), and health professional shortage areas (HPSAs) designations.

If you have questions about these designations please contact the HRSA
Information Center at 1-888-275-4772, (press option 1, and then option
2) or the Shortage Designation Branch 301-594-0816.

6)  **Attachment 6: Job or Position Descriptions for Key Personnel and
    Biographical Sketches of Key Personnel**

It is recommended that the job descriptions be limited to one page in
length to the extent possible, and 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. Item 6 in the Program Narrative section of the PHS 5161-1 Form
provides additional guidance on items to include in a job description.

Include biographical sketches for persons occupying the key positions
that have been described in Attachment 4 (Job or Position Descriptions),
not to exceed two pages in length each. Applicants should also indicate
any current vacancies in key personnel. 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, *for Public Entities* (As
    applicable)**

Public entity applicants such as State, county or local health
departments, certain types of public hospitals and universities, can
partner with a health center to comply with all the health center
governance requirements and regulations. If applicable, public entity
applicants should include a copy of the complete and executed
co-applicant agreement indicating each party's role, responsibilities,
and authorities in accordance with section 330, the implementing
regulations, and applicable policies. The co-applicant agreement should
be submitted in its entirety, and be signed and dated by both the public
entity and co-applicant governing board. For more information about
co-applicant arrangements, please review PINs 97-27 and 98-24 described
on p.17 of this guidance. If not applicable, please state this on one
page and attach.

8)  **Attachment 8: Sub-recipient Documentation (As applicable)**

Applicant organizations proposing a sub-recipient relationship MUST
submit all necessary documentation to demonstrate that the sub-recipient
is in compliance with section 330 requirements (i.e., sub-recipient
agreement, sub-recipient's bylaws and articles of incorporation) in
order to meet the definition of a federally qualified health center.
Please review Appendix F, page
[145](#definitions-for-new-access-point-applications), for a definition
of sub-recipients. If not applicable, please state this on one page and
attach.

9)  **Attachment 9: Contracts, agreements, etc., (As applicable or
    required)**

Provide any documents that describe substantive working relationships
between the applicant agency and other agencies and programs cited in
the proposal (e.g., contracted provider and/or staff, management
services contracts, etc). Documents that confirm actual or pending
contractual agreements should clearly describe the roles of the
subcontractors and any deliverable. Applicants should include any
building lease, or intent to lease in Attachment 8. All letters of
agreements and/or contracts [must]{.underline} be dated and signed. If
not applicable, please state this on one page and attach.

As a reminder, contracts must be in compliance with section 330 of the
Public Health Service Act and procurement contracts must comply with 45
CFR Part 74. In addition, the health center's governing board must
approve all contracts and retain authority over the health center's
policy and procedures, such as budget, hours, services provided.

10) **Attachment 10: Most recent independent financial audit**

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

11) **Attachment 11: Articles of Incorporation**

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

12) **Attachment 12: Internal Revenue Service (IRS) Tax Exempt
    Certification or W-9**

Applicants must submit a copy of the IRS Tax Exempt Certificate or a
copy of the application for such certificate. The IRS Tax Exempt
Certification or a copy of the organization's W-9 Form must be submitted
to verify the organizational Employee Identification Number. Public
entity applicants must provide the IRS Tax Exempt Certification and the
W-9 Form for the Co-Applicant Board.

13) **Attachment 13: Letters of Support**

The applicant should include any dated letters of support as appropriate
to demonstrate support and commitment to the proposed new access point.
As necessary, applicants should also include a one-page list of all
additional support letters that are not included in the application, but
are available onsite.

14) **Attachment 14: Discount Sliding Fee Schedule**

Applicants must provide a proposed schedule of discounts that
corresponds to a schedule of charges for which discounts are adjusted on
the basis of the patient's ability to pay. In addition, applicants must
show discounts for persons with incomes below 200 percent of the Federal
poverty level (see the most current Federal poverty guidelines at
<http://aspe.hhs.gov/poverty/>).

15) **Attachment 15: Other Relevant Documents (As applicable)**

Applicants may include other attachments and documents to the
application, as applicable, to support the proposed project.

**Applicants are reminded that failure to include all required documents
as part of the application may result in an application being considered
incomplete or non-responsive. Applications are limited to no more than
200 pages IN TOTAL including all required and optional documents. Any
application that exceeds the specified limits (200 pages when printed by
HRSA, approximately 20 MB) will be deemed non-compliant and will be
returned to the applicant without further consideration.** **It is
highly recommended that applicants print out the application before
submitting it electronically to ensure that it is within the 200-page
limit.**

[]{.mark}

## 3. Submission Dates and Times {#submission-dates-and-times .unnumbered}

### Letter of Interest {#letter-of-interest .unnumbered}

The submission of a Letter of Interest (LOI) is recommended but not
required in order to submit a new access point application in FY 2007.
Past history has shown that applicants have benefited from the feedback
provided through the LOI process.

Applicants are encouraged to submit a LOI to the HRSA as soon as it
begins considering an application for Federal support of a new access
point. The HRSA uses the LOI process to provide feedback to the
organization to improve the quality of its application and its
opportunity for funding consideration in FY 2007. Through this process
the HRSA will examine whether the proposal is consistent with the
objectives of the Consolidated Health Center Program, demonstrates
readiness to initiate the project, and assures the completeness of the
need for assistance data. **HRSA will provide feedback within 30-days of
receipt of the LOI; therefore, it is recommended that organizations
submit the LOI as soon as possible in order to integrate the HRSA
response into the application.**

The LOIs should be less than 7 pages and address the level of need in
the community for additional primary care services and a brief
description of the proposed project and the stage of readiness for
initiating operations. It is recommended that each LOI include the
following:

(a) a brief description of the new access point project being proposed:
    the location and sponsoring organization;

(b) a brief description of the proposed target population (identify any
    special populations to be served) and service area including
    whether (1) it is defined as urban or rural and (2) identification
    of any federally-designated Medically Underserved Area
    (MUA)/Medically Underserved Population (MUP) designations (not
    required for HCH, MHC or PHPC applicants);

(c) a brief description of issues creating a high need for primary
    health services for the target population including any significant
    or unique barriers to care;

(d) a brief description of other providers of care in the service area
    including any other federally qualified health centers, other
    available health care resources in the area and any proposed
    partnerships;

(e) a brief description of all health care services to be provided
    including primary care, mental health, substance abuse, and oral
    health care services as well as the mechanism of the provision of
    each service (e.g., direct service, referral, etc.)

(f) a brief description of the proposed applicant organization, stage of
    development and ability to meet requirements for program compliance;

(g) a brief discussion of the readiness to receive funding including
    that the facility(ies) identified for the new access point(s) will
    be operational and providers will be available within 120 days of a
    grant award.

(h) a completed Need For Assistance Worksheet (Form 9 -- Part B, page
    [122](#form-9-part-b-need-for-assistance-worksheet-fy-2007)).

(i) a map of the proposed service area identifying proposed new access
    point location(s) as well as any other primary care providers.

LOIs may be sent via e-mail to <LOIs@HRSA.GOV>, faxed to 301-480-7225,
or mailed to:

> **Division of Policy and Development**
>
> **HRSA, Bureau of Primary Health Care**
>
> **ATTN: New Access Point LOI**
>
> **5600 Fishers Lane, Mailstop 17-61**
>
> **Rockville, Maryland 20857**

It is also recommended that a copy of the LOI be sent to the appropriate
PCA and PCO. After a LOI is submitted and feedback is provided,
applicants are encouraged to work with the PCAs, PCOs and NOs to develop
the strongest possible application for funding. (See Appendix E, page
[126](#primary-care-association-primary-care-office), for a complete
list of PCAs, PCOs and NOs).

### Application Due Dates  {#application-due-dates .unnumbered}

The due date for applications under this grant announcement is *December
6, 2006 at 8:00 P.M. ET*. Applications will be considered as meeting the
deadline if they are E 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. **To ensure that you
have adequate time to follow procedures and successfully submit the
application, we recommend you register immediately in Grants.gov (see
Appendix B) and complete the forms as soon as possible, as this is a new
process and may take some time.**

**Please refer to Appendix B for important specific information on
registering, and Appendix A, Section 3 for important information on
applying through Grants.gov.**

### Late Applications {#late-applications .unnumbered}

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.

## 4. Intergovernmental Review {#intergovernmental-review .unnumbered}

**The Consolidated 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 SPOCs 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>. For proposed
projects serving more than one State, the applicant is advised to
contact the SPOC of each affected State.

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.

The due date for State process recommendations is 60 days after the
applicable Federal application receipt due date. The HRSA does not
guarantee that it will accommodate or explain its responses to State
process recommendations received after the 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.

-   A summary of the services to be provided, and

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

## 5. Funding Restrictions {#funding-restrictions .unnumbered}

Applicants responding to this announcement **may not request funding
greater than the allowable cap of \$650,000 per year in Federal funds
for new access point applications**. New starts will be awarded project
periods up to three years; satellite applicants will have awards aligned
with the base grant. Awards to support new access points 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 and Attachment
2 of this application guidance for further information and instruction
on the development of the application budget.

Consistent with the statutory restrictions, section 330 funds may
**[not]{.underline}** be used for grant writing or construction of
facilities. Funds may, however, be used for minor capital cost including
equipment and minor alteration and renovation of facilities (see
definition, page [145](#definitions-for-new-access-point-applications))
for use as new access points. Applicants may request to use up to
\$150,000 of Federal funds in the first year for such minor capital cost
but the total Federal section 330 funds requested may not exceed the
established cap of \$650,000 in any year.

## 6. Other Submission Requirements {#other-submission-requirements .unnumbered}

As stated in Section IV.1, except in rare cases, HRSA will no longer
accept applications for grant opportunities in paper form. Applicants
submitting 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 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. 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. 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 following address and received by
HRSA by no later than five days after the date of submission in
Grants.gov:

The HRSA Grants Application Center

The Legin Group, Inc.

Attn: *New Access Point*

Program Announcement No. HRSA-07-067

CFDA No. 93.224

910 Clopper Road

Suite 155 South

Gaithersburg, MD 20878

Telephone: 877-477-2123

Applications will be considered as having met the deadline if: (1) the
application has been successfully transmitted electronically by your
organization's Authorizing Official (AO) 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 the date of submission in
Grants.gov.

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.

# Application Review Information 

## 1. Review Criteria {#review-criteria .unnumbered}

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.

The following eight Review Criteria will be used to review and rank
applications. 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. In addition, the Program Narrative must address the
appropriate health center specific elements which follow at the end of
each section as appropriate.

As a reminder, the new access point application is expected to reflect
the scope of the application submitted, as appropriate. Therefore**, new
start applicants** should include information on the entire scope of the
proposed project and **satellite applicants** should address only the
service area of the new site(s) (i.e., only the new area proposed under
the satellite, not the entire service area of the applicant).

The eight (8) Review Criteria for the HRSA-07-067 New Access Points
funding opportunity and maximum points awarded are as follows:

[]{.mark}

**Criterion 1: NEED (10 points)**

1.  []{#_Ref81217154 .anchor}Applicant describes the service
    area(s)/community(ies) to be served by the new access point(s),
    including:

    a.  The service area population and the area to be served (i.e.
        urban, rural, sparsely populated \[7 or less people per square
        mile\]).

    b.  The county(ies), census tracts, minor civil divisions,
        schools/school districts, etc., in the service area.

    c.  Any Medically Underserved Areas (MUAs), Medically Underserved
        Populations (MUPs), and Health Professional Shortage Areas
        (HPSAs), as applicable.

2.  Applicant describes the target population(s) for the new access
    point(s) (e.g., general community members, migrant/seasonal
    agricultural workers, residents of public housing, homeless persons,
    etc.), including:

    a.  The unserved and underserved populations in the community,
        including any other populations that are in need of access to
        primary health care (e.g., elderly population, recent immigrant
        population, migrant/seasonal farmworkers, homeless populations,
        residents of public housing, low-income school
        children/adolescents and their families).

    b.  The unique demographic characteristics of the target population
        (e.g., age, gender, insurance status, unemployment, poverty
        level, ethnicity/culture, education, etc.).

3.  Applicant demonstrates an understanding of the most common causes of
    mortality, morbidity, and the incidence and prevalence of chronic
    and infectious diseases and the need for services to prevent or
    lessen the impact in the target population.

4.  Applicant identifies and describes the most significant barriers to
    care, gaps in services, significant health disparities and the major
    health care problems in the community that will be addresses by the
    new access point(s). This should include a description of:

    a.  any culturally specific characteristics that impact access to
        and the delivery of health care services;

    b.  the relevant geographic barriers to care and other factors
        impacting access to care;

    c.  the major and/or unique health care needs of the target
        population(s); and

    d.  the most common causes of mortality and the incidence and
        prevalence of chronic and infectious diseases

> (The Health Care and Business Plans should present goals and
> measurable, time-framed objectives to address these identified needs.)

5.  Applicant describes any significant changes over the past year in
    the service area or population being served impacting on the need
    for services (e.g., influx of refugee population, or closing of
    local factory, etc.). This should include a description of any
    significant changes for each target population type served (i.e.,
    CHC, MHC, HCH, and/or PHPC).

6.  Applicant identifies other clinical primary and preventive
    healthcare providers, including mental health/substance abuse and
    oral health providers. In addition, section 330 grantees, FQHC
    Look-Alikes, other HRSA and non-HRSA federally-funded grantees,
    hospitals, public/private resources and/or services within the
    proposed service area that are providing care to the target
    population(s) should be identified as applicable. The applicant also
    evaluates the capacity of available resources and/or services in
    providing care to the proposed target community/population.

7.  Applicant demonstrates a thorough understanding of the health care
    environment including:

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(a) The impact in the State of the implementation of SCHIP, 1115 and
    1915(b) waivers, State Medicaid prospective payment system; Medicaid
    managed care, State laws, current and proposed welfare reform
    initiatives, etc.; and

(b) The impact that these changes have had on the access to services or
    demand for services among the target population(s), on the ability
    to respond to patient demand, and/or on the fiscal stability of the
    organization.

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```
8.  Applicant demonstrates how the proposed new access point aligns with
    priorities in the State for increasing access to care for the
    underserved.

***In addition to the above criteria, applicants requesting funding for
a new access point(s) for the following types(s) of health center must
also respond to these health center type-specific criteria:***

*MHC APPLICANTS:*

(a) Applicant describes the major agricultural area/environment, the
    growing seasons, the crops and their impact on the health of
    Farmworkers and their families, including a discussion of any impact
    on the demand for services among migrant and seasonal farmworkers
    (i.e., the need for hand labor or the number of temporary workers,
    etc.).

*HCH APPLICANTS:*

(a) Applicant describes the availability of housing in the community and
    the impact of this and other factors on the demand for services
    among homeless individuals and families.

*PHPC APPLICANTS:*

(a) Applicant describes any recent changes in the availability of public
    housing to serve area residents and the impact on the demand for
    services among residents in the targeted public housing communities
    served.

[]{.mark}

[]{.mark}

**Criterion 2: RESPONSE (30 points)**

1.  []{#_Ref81217206 .anchor}Applicant describes the scope of the
    proposed project (see Definitions, page
    [145](#definitions-for-new-access-point-applications)) including the
    proposed service delivery model (e.g., freestanding, single or
    multi-site, migrant voucher, mobile site, or combination), and
    locations/settings where services are to be provided.

2.  Applicant demonstrates that the proposed model is most appropriate
    and responsive to the identified community health care needs (i.e.,
    the service delivery plan addresses the priority access to care,
    health and social problems of the target population(s) for all the
    major life cycles and for each special population to be served
    (i.e., migrant, homeless, residents of public housing)).

3.  Applicant discusses how the required primary, preventive and
    supplemental health services (e.g., enabling services, eligibility
    assistance, outreach, and transportation) will be provided (e.g.,
    directly, via contract, referral system, etc.) to all lifecycles of
    the target population and for each special population to be served
    (i.e., migrant or seasonal farmworkers, homeless individuals or
    families, residents of public housing)) by the new access point(s).

4.  Applicant demonstrates that it has established a schedule of charges
    for services and corresponding schedule of discounts based on a
    person's ability to pay (i.e., sliding fee scale) for all persons at
    or below 200 percent of poverty so that all of the required primary,
    preventive and supplemental health services will be available and
    accessible to the target population without regard to ability to
    pay.

5.  Applicant demonstrate a clear and defined plan for providing (a)
    oral health care services and (b) mental health care and substance
    abuse related services, that assures availability and accessibility
    to the target population either directly on-site or through
    established arrangements (e.g., directly, contract, referral, etc.)
    without regard of ability to pay.

6.  Applicant demonstrates that the service delivery plan includes
    participation in a disease/care management and system improvement
    program to address major chronic disease incidences with the target
    population.

7.  Applicant demonstrates that the services will be culturally and
    linguistically appropriate by describing the cultural and linguistic
    diversity of the target population and describing how the applicant
    will address their needs..

8.  Applicant demonstrate comprehensiveness and continuity of care for
    the new access point(s), including a discussion of the following:

    a.  Hours of operation that assure services are available and
        accessible at times meeting the needs of the population
        including evenings and weekends as appropriate;

    b.  Mechanism to assure professional coverage during the hours when
        the health center is closed; and

    c.  Case management system that demonstrates coordination at all
        levels of health care, including arrangements for referrals,
        hospital admissions discharge planning and patient tracking.

9.  Applicant demonstrates that the development of the new access point
    is the result of a strategic planning process that examined the
    needs of the community and included community input and Board
    involvement.

10. Applicant demonstrates collaboration and coordination of services
    with other providers including other existing FQHCs and section 330
    grantees in the area. This should include a description of both
    formal and informal collaborative and partner arrangements, which
    assure a seamless continuum of care and access to appropriate
    specialty care for the target population(s). Applicant provides
    copies of relevant contracts, MOUs, letters of commitment or
    investment (e.g., from the school board, local hospital, public
    health department, etc.), as part of the application attachments.

11. Applicant demonstrates that the proposed clinical staffing pattern
    for the new access point(s) is appropriate for the level and mix of
    services to be provided (e.g., number and mix of primary care
    physicians and other providers and clinical support staff, language
    and cultural appropriateness, etc.).

12. Applicant describes a detailed plan for recruiting and retaining
    appropriate health care providers as appropriate for achieving the
    proposed staffing pattern.

13. Applicant discusses the development and implementation of an
    emergency preparedness and management plan and discusses
    participation or plans to participate with State and local emergency
    planners.

***Health Care Plan***

14. Applicant clearly outlines a Health Care Plan Table with measurable
    goals and objectives toward improving patient health outcomes,
    eliminating health disparities, and increased access to primary and
    preventive healthcare services for the target populations and major
    life cycles in the Health Care Plan (see Guidelines for developing
    the Health Care Plan in Appendix C).

> **Applicant addresses the required immunization and chronic disease
> measures as specified in the Health Care Plan Instructions (see page
> [88](#developing-the-health-care-plan-and-business-plan)).**
>
> Where appropriate, applicants 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
> Healthy People 2010 objectives, Health Disparities Collaboratives
> measures, Health Plan Employer Data and Information Set (HEDIS)
> measures, accreditation standards, Relative Value Units and measures
> developed from previous HRSA Office of Performance Review site visits.

***Business Plan***

15. Applicant clearly outlines a Business Plan with time-framed,
    measurable and targeted goals/objectives for the operation of the
    health center and ties them into the overall long-term success of
    the health center. Applicant demonstrates through the Business Plan
    that operational issues will be addressed and that the
    administrative, financial and clinical systems are appropriate for
    the proposed project. For each activity, applicants should include:

    a.  Problem/need statement;

    b.  Key action steps and activities that will be implemented to
        accomplish the project period end goals and budget year end
        objective identified in the Business Plan;

    c.  Data that will be reported;

    d.  The mechanism by which the organization identifies and responds
        to the community and its needs (patient surveys, community needs
        assessments, etc.); and

    e.  Person (s) and area of the health center's operations for
        tracking, evaluation and completion of the objectives and key
        actions steps. (see sample chart in Appendix C)

***In addition to the above criteria, applicants requesting funding for
a new access point(s) for the following types(s) of health center must
also respond to these health center type-specific criteria:***

*MHC APPLICANTS:*

(a) Applicant describes how the service delivery plan for the new access
    point is responsive to the health care needs associated with the
    environmental and/or occupational hazards to which farmworkers and
    their families are exposed, and demonstrates how these needs will be
    met.

(b) Applicant describes the setting(s) in which health and enabling
    services will be provided, i.e., special arrangements to provide
    services at camps and/or farms; use of mobile teams and or vans;
    extended hours/weekend services; etc.

(c) Applicant describes an outreach program that will increase access to
    primary and preventive health care services and how the outreach
    program is integrated into the primary care delivery system.

(d) Applicant discusses any network of support for migrant and seasonal
    Farmworkers and their families. This should include a discussion of
    linkages (e.g., MOAs, MOUs, contracts, etc.) with other migrant
    health organizations such as Migrant Education, Migrant Head Start,
    and Migrant WIC programs. Copies of appropriate signed agreements,
    contracts, etc should have been submitted in the Appendix.

*HCH APPLICANTS:*

a.  Applicant describes the arrangements for providing required
    substance abuse services, which may include detoxification, risk
    reduction, outpatient treatment, residential treatment and
    rehabilitation for substance abuse.

b.  Applicant describes an outreach program that will increase access to
    primary and preventive health care services and inform homeless
    people of the availability of services at the new access point and
    how this outreach program is integrated into the primary care
    delivery system.

c.  Applicant documents the relationship with and the coordination of
    services at the new access point with providers of housing, job
    training, and other essential supports for persons who are homeless.

d.  Applicant describes the scope of the case management services at the
    new access point to address the health, housing and social service
    needs of homeless persons.

e.  Applicant documents participation in community-wide planning on
    behalf of homeless persons through participation with homeless
    coalitions, advocacy groups, and the existing continuum of care
    organizations in their community.

*PHPC APPLICANTS:*

(a) Applicant provides documentation that the location of the proposed
    new access point service site(s) is (are) in or directly adjacent to
    the public housing community(ies) being targeted.

(b) Applicant provides a formal agreement with the local public housing
    authority that demonstrates access to on-site space for the new
    access point, where applicable.

(c) Applicant describes how residents will be involved in the planning
    for and administration of the new access point.

**Criterion 3: EVALUATIVE MEASURES (10 points)**

1.  []{#_Ref143938280 .anchor}Applicant describes its quality
    improvement systems for health center services, and its ability to
    monitor and evaluate the outcomes of the services provided (e.g.,
    adequate management information systems, established quality
    assurance program, patient feedback). including:

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(a) an evaluation plan with specific time framed, measurable outcomes
    and clear methods/action steps; and

(b) the mechanism(s) by which the organization identifies and responds
    to the community and its needs (e.g., patient surveys, needs
    assessments, statewide data, census data).

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```
2.  Applicant describes a performance improvement system that monitors
    and evaluates progress toward eliminating disparities in health
    outcomes, reducing patient risk, improving patient satisfaction,
    credentialing and privileging, incident reporting, and integrates
    planning, management, leadership and governance into the evaluation
    processes of program effectiveness.

3.  Applicant demonstrates the role of clients, community, staff and
    Board of Directors in establishing and evaluating the organization's
    objectives and priorities.

4.  Applicant demonstrates how strategic planning and program
    decision-making result from the evaluation of program effectiveness
    by management staff and the Governing Board.

**Criterion 4: IMPACT (10**[]{#_Ref81217265 .anchor} **points)**

1.  Applicant identifies how many people will be served (users) and
    encounters generated by the new access point(s) after the first year
    of operation and at full operational capacity (at the end of 2
    years) through the proposed new access point project. Applicant must
    include the number of users and encounters for each special
    population, (i.e., migratory and seasonal farmworkers, homeless
    individuals and families, and/or residents of public housing) if
    funds are requested for one or more of these populations. If the new
    access point(s) is already operational, the applicant identifies how
    many people are currently served and how many additional persons
    will be served and encounters generated after the first year of
    operation and at full operational capacity. This information should
    be consistent with the information presented on Form 1 -- Part A:
    General Information Worksheet (page [Error: Reference source not
    found](#_Ref76195506) of this document)

2.  Applicant demonstrates and provides evidence of the community's
    support for the proposed new access point(s). Letters of support and
    MOUs and/or a list of additional letters of commitment, MOUs, etc.,
    on file at the health center, should be included as appropriate in
    the Appendices.

3.  Applicant demonstrates the extent to which the proposed new access
    point(s) will increase access to care and eliminate major barriers,
    address the priority health care needs and reduce health disparities
    for the medically underserved in the community/target population(s)
    to be served. In cases where the proposed new access point site(s)
    are already operational, how section 330 funds will
    augment/supplement existing services, resources and providers to
    expand accessibility and availability of primary health care
    services to underserved populations.

4.  Applicant describes how the proposed new access point project
    correlates to the goals and objectives of the Healthy People 2010
    initiative, specifically to (1) increase the quality and years of a
    healthy life; and (2) eliminate our country's health disparities.

5.  Applicant demonstrates appropriate collaboration with other area
    providers (including other FQHCs and section 330 funded programs),
    to minimize duplication of services and assure an effective
    continuum of care.

**Criterion 5: RESOURCES/CAPABILITIES (15 points)**

1.  []{#_Ref81217291 .anchor}Applicant discusses why it is the
    appropriate entity to receive funding in terms of factors such as:
    staff skills, organizational capacity, clinical outcomes, cultural
    and linguistic competence, evaluation capabilities, unique
    characteristics and significant accomplishments of the organization,
    etc.

2.  Applicant describes prior experiences and expertise in:

> \(a\) Working with the target population(s);

(a) Addressing the identified health care needs; and

(b) Developing and implementing appropriate systems and services to meet
    the needs of the community/population to be served.

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3.  Applicant describes the organizational structure for the new access
    point (including parent organization, corporate affiliation, etc.)
    is compliant with section 330 requirements, appropriate, and
    adequate for the size and scope of the proposed project \[CHC and/or
    MHC applicants must complete FORM 8 -- Part A, page
    [113](#form-8--part-a-health-center-affiliation-certification) and
    as appropriate, FORM 8 -- Part B, page
    [114](#form-8-part-b-health-center-affiliation-checklist)\].

4.  Applicant demonstrates that the key management staff (e.g. CEO, CFO,
    CMO) of the health center is appropriate and that the process for
    hiring key management staff \[see PINs 98-23 and 98-24\] is in
    accordance with Health Center Program Expectations. This should
    include a description of any specific leadership for each health
    center type (i.e. CHC, MHC, HCH, or PHPC), as applicable.

5.  Applicant discusses the proposed staffing plan and demonstrates that
    it is appropriate for the proposed new access point project. The
    staffing plan should be consistent with the completed Form 2:
    Proposed Staff Profile (see page
    [97](#form-2-proposed-staff-profile)). Position descriptions that
    include the roles, responsibilities, and qualifications of proposed
    key project staff should be included in the Appendix. Copies of
    biographical sketches, resumes or CVs for any key employed personnel
    that will be assigned to work on the proposed project must also be
    included in the Appendix, when applicable.

6.  Applicant demonstrates that the operational, administrative,
    financial and clinical systems are appropriate for the new access
    point project. Applicant also demonstrates that these systems are
    able to collect, organize and analyze data for reporting and are
    able to accurately reflect the financial performance of the
    organization to support Board and management decision-making.

7.  Applicant demonstrates financial viability and accounting and
    internal controls in accord with sound financial management
    procedures that are appropriate to the size of the organization,
    funding requirements, and staff skills available. The most recent
    financial audit and management letter should also be included in the
    Appendix, when applicable.

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

1.  []{#_Ref81217320 .anchor}Applicant demonstrates in the budget
    presentation, three 12-month annualized budgets which are
    appropriate and reasonable in terms of:

> \(a\) The level of requested Federal grant funds versus total budget
> for each year;

(b) The total resources required to achieve the goals and objectives of
    the proposed service delivery plan (i.e., total project budget);

(c) The maximization of non-grant revenue relative to the proposed plan
    and other Federal/State/local/in-kind resources applied to the
    project;

(d) The projected patient income for each year is reasonable based on
    the patient mix and number of projected users and encounters;

(e) The number of proposed users and encounters;

(f) The total cost per user and encounter;

(g) The total federal section 330 grant dollars per user; and

(h) The one-time minor capital costs.

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2.  Applicant demonstrates that the Federal grant funds requested are
    being used to (a) leverage other sources of funding and (b) expand
    services and capacity to provide services. If the applicant is
    purchasing/taking over/assuming a clinic(s) operation as part of the
    proposal, the applicant must demonstrate the level of continued
    commitment and collaboration of the other organization to assure the
    viability of the clinic operation.

3.  Applicant demonstrates that the business plan goals and objectives
    are targeted and demonstrate appropriate financial planning in the
    development of the proposal and for the long-term success of the
    project.

4.  Applicant describes how the proposed health center is a
    cost-effective approach to meeting the primary care needs of the
    target population given the health care needs of the target
    population and the level of health care resources currently
    available in the community.

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

*Applicant must provide a copy of the signed bylaws demonstrating
compliance with and reflecting all functions and responsibilities cited
in section 330, as appropriate. Please refer to 42 CFR 51c.304
(available online at: <http://www.gpoaccess.gov/cfr/retrieve.html>) and
PIN 98-12 (see p.17 of this guidance) for additional information on the
governance requirement (available online at:
<http://www.gpoaccess.gov/cfr/retrieve.html>).*

1.  []{#_Ref81217357 .anchor}Applicant describes the structure of the
    Board in terms of size, expertise, and representativeness of the
    communities/populations to be served by the new access point(s)
    (e.g. appropriate racial/ethnic, economic status, and gender
    representation, minimum 51% consumer majority, etc.). If requesting
    funding under more than one section 330 program to support a new
    access point(s), applicant demonstrates appropriate representation
    from the populations served by the health center.

2.  Applicant discusses measures for assuring that the Governing Board
    is/remains compliant with section 330, appropriate and applicable
    regulations and HRSA Program Expectations.

3.  Applicant discusses the mechanism for continued Governing Board
    training, including training new governing board members in
    appropriate responsibilities and requirements of the Federal grant.

4.  Applicant describes the provision for ensuring monthly meetings of
    the Governing Board.

5.  Applicant describes the strategic planning activities of the
    Governing Board, the mechanism used by the Board to evaluate its
    effectiveness and how this is utilized as part of the Board's short-
    and long-term strategic planning efforts.

6.  Applicant demonstrates that the Governing Board has appropriate
    oversight responsibilities, specifically the responsibility to:

> \(a\) directly employ, select/dismiss and evaluate the CEO/Executive
> Director;

(b) approve the health center\'s annual budget;

(c) adopt general policies and procedures and establish priorities and
    activities;

(d) schedule hours of operation for which services will be provided;

(e) establish personnel policies and procedures, including selection and
    dismissal procedures, salary and benefit scales, employee grievance
    procedures, and equal opportunity practices;

(f) adopt policy for financial management practices, including a system
    to assure accountability for center resources, approval of the
    annual project budget, center priorities, eligibility for services
    including criteria for partial payment schedules, and long-range
    financial planning;

(g) evaluate center activities including services utilization patterns,
    productivity of the center, patient satisfaction, achievement of
    project objectives, and development of a process for hearing and
    resolving patient grievances;

(h) assure that the center is operated in compliance with applicable
    Federal, State, and local laws and regulations; and

(i) adopt health care policies including scope and availability of
    services, location and hours of services, and quality-of-care audit
    procedures.

***In addition to the above criteria, applicants requesting funding for
a new access point(s) for the following types(s) of health center must
also respond to these health center type-specific criteria:***

*HCH, PHPC, and MHC APPLICANTS:*

a.  If applicable, applicant clearly identifies a request for a waiver
    of governance requirements. If a waiver is requested, applicant
    identifies on Form 6 -- Part B (page
    [110](#form-6-part-b-request-for-waiver-of-governance-requirements))
    which requirements are requested to be waived and discusses
    alternative arrangements proposed in lieu of required elements.
    \[See PIN 98-12, "Implementation of Section 330 Governance
    Requirements" (signed April 28, 1998)\]. No waivers will be accepted
    for applicants requesting support for a new access point(s) or
    already receiving funding under the CHC program.

**Criterion 8: READINESS (5 points)**

1.  []{#_Ref81217379 .anchor}Applicant provides evidence that the
    proposed facility(ies) is available. Provide appropriate
    documentation (e.g., lease agreement, intent to lease, as
    appropriate).

2.  Applicant describes the proposed facility(ies) and demonstrates that
    the proposed facility(ies) is located appropriately for serving the
    target population based on such issues as transportation, population
    density, and available providers.

3.  Applicant demonstrates that the size of the new access point
    facility(ies) and number of exam rooms is appropriate and reasonable
    in terms of the projected number of users at full operational
    capacity, the proposed level of staffing and scope of services to be
    provided. Applicant provides floor plans.

4.  Applicant demonstrates that the proposed timeline for initiating
    services is reasonable to assure the new access point site(s) will
    be operational, appropriate staff and providers will be available
    and services will be provided within 120-days of a grant award as
    expected. Provide appropriate documentation (e.g., renovation plans,
    provider contracts, and commitment letters, as appropriate).

***In addition to the above criteria, applicants requesting funding for
a new access point(s) for the following types(s) of health center must
also respond to these health center type-specific criteria:***

*FOR HCH, MHC, AND PHPC APPLICANTS*:

\(a\) Applicant includes, where appropriate, an agreement from site
sponsor to allow applicant organization to provide services at specified
location.

## 2. Review and Selection Process {#review-and-selection-process .unnumbered}

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 need for assistance component of the application will be evaluated
first by the Objective Review Committee (ORC) based on responses
presented in the completed Form 9 -- Part B (page
[122](#form-9-part-b-need-for-assistance-worksheet-fy-2007) of this
document) using the need for assistance criteria (see Form 9 -- Part A,
page [116](#form-9-part-a-need-for-assistance-worksheet-criteria), for
scoring of the need for assistance criteria) with points assigned up to
a maximum of 100 points. Applicants that score 70 or higher on the need
for assistance component of the application will have the technical
merits of the proposal evaluated by the ORC using the review criteria
presented in this application guidance with points assigned up to a
maximum of 100 points total (see Section IV, page [36](#_Ref76210219)).
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.
The funding preference (see below) will be determined by the reviewers
based on supporting documentation contained in the application.

HRSA reserves the right to review fundable applicants for compliance
with HRSA program expectations through a review of site visits, audit
data, Uniform Data System (UDS) or similar reports, Medicare/Medicaid
cost reports, external accreditation or performance review reports, etc.
as applicable, before a final recommendation for funding is made.

All new access point applications will be reviewed initially for
eligibility (see Section III, page [13](#eligibility-information), for
eligibility requirements), completeness (see Section IV for Application
Format, page [17](#application-format-requirements), for a list of
required documents to be submitted as part of the new access point
application) and responsiveness to the application. **Those applications
that are determined to be ineligible, incomplete or non-responsive to
the grant application guidance and/or section 330 program requirements
will be returned without further consideration.**

### Funding Preferences  {#funding-preferences .unnumbered}

The authorizing legislation provides a funding preference for some
applicants. Applicants requesting and receiving the preference may be
placed in a more competitive position among applications considered for
funding. Applications that do not receive a funding preference will be
given full and equitable consideration during the review process. It
should be noted that other factors, including those listed below in
Other Awarding Factors, will be considered as part of the selection of
applications for funding.

The funding preference will be determined by the reviewers based on
supporting documentation contained in the application. The law provides
that a funding preference be granted to any qualified applicant that
specifically requests the preference and meets the criteria for the
preference as follows:

> *Sparsely Populated Rural Frontier Areas*: In order to be considered
> for a funding preference, an applicant must demonstrate that the
> entire area to be served by the proposed new access point has seven or
> less people per square mile (i.e., the entire service area for the new
> access point must have seven or less persons per square mile and may
> not be broken into pieces (e.g., specific census tracts within the
> defined service area)). Applicants requesting consideration of a
> funding preference must indicate the request on FORM 1-A, and provide
> documentation indicating the entire area to be served has seven or
> less people per square mile (e.g., information from the Census
> Bureau).

### Other Awarding Factors {#other-awarding-factors .unnumbered}

HRSA intends to achieve a wide distribution of new access point awards
in FY 2007. HRSA will consider all of the following factors, in addition
to the preference indicated above, in making awards for new access
points in FY 2007.

> *RURAL/URBAN DISTRIBUTION OF AWARDS:*
>
> Aggregate awards in FY 2007 to serve rural and urban areas will be
> made to ensure that no more than 60 percent and no fewer than 40
> percent of the people served come from either rural or urban areas.
>
> *PROPORTIONATE DISTRIBUTION*
>
> Aggregate awards in FY 2007 to support the various types of health
> centers (i.e., 330(e) Community Health Centers, 330(g) Migrant Health
> Centers, 330(h) Health Care for the Homeless Health Centers, and
> 330(i) Public Housing Primary Care Health Centers) will be made to
> ensure continued proportionate distribution of funds across the
> Consolidated Health Center Program as set forth in section
> 330(r)(2)(B) of the Public Health Service Act.
>
> *GEOGRAPHIC CONSIDERATION:*
>
> The goal of the HRSA in making this funding announcement is to expand
> the current safety net on a national basis by creating new access
> points in areas not currently served by a funded health center.
> Therefore, the HRSA will consider geographic distribution when
> deciding which applications to fund. Please also be advised if
> considering submissions under more than one new access point funding
> opportunity \[HRSA-07-067 or HRSA-07-069: New Access Points in High
> Poverty Counties\], HRSA will issue no more than one new access point
> award per organization in FY 2007.
>
> *PERFORMANCE UNDER SECTION 330 PROGRAM EXPECTATIONS:*
>
> Current HRSA grantees found to be out of compliance with section 330
> program expectations may not be considered for funding.

[]{.mark}

## 3. Anticipated Announcement and Award Dates {#anticipated-announcement-and-award-dates .unnumbered}

One application cycle has been announced for new access point
applications for FY 2007. It is the responsibility of the applicant to
ensure that the complete application is submitted through Grants.gov by
the published due date. Applications under HRSA-07-067 received by
8:00pm on December 6, 2006 deadline will be reviewed with funding
decisions announced on or about May 1, 2007. Applications submitted
electronically or E marked after December 6, 2006, will not be accepted
for processing and will be returned.

# Award Administration Information

## 1. Award Notices {#award-notices .unnumbered}

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. It will be sent prior to the
start date, anticipated to be May 1, 2007.

## 2. Administrative and National Policy Requirements {#administrative-and-national-policy-requirements .unnumbered}

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

[]{.mark}

### Public Policy Issuance {#public-policy-issuance .unnumbered}

**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 at the Healthy People 2010 website:
http://www.health.gov/healthypeople/document.

### Smoke Free Workplace {#smoke-free-workplace .unnumbered}

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.

## 3. Reporting {#reporting .unnumbered}

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.

**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. More
> specific information will be included in the award notice.
>
> 2\. Submit a **Progress Report** seven months after the award of
> funds. Further information will be provided in the award notice.
>
> 3\. **Uniform Data System**. 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 the HRSA uses 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 {#d.-performance-review .unnumbered}

> 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. On a regularly scheduled
> basis, HRSA grantees are required to participate in a 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 are
> expected to prepare an Action Plan that identifies key actions to
> improve program performance as well as addresses any identified
> program requirement issues. Performance reviews also provide 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>.

# Agency and National Organization Contacts

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

Angela Stokes

Health Services Branch

HRSA, Division of Grants Management Operations

5600 Fishers Lane, Rm. 11A-16

Rockville, MD  20857-0001

Telephone:  301-594-5296

Fax:  301-594-6096

Email:  angela.stokes@hrsa.hhs.gov

Additional information related to the overall program issues may be
obtained by contacting:

Preeti Kanodia

New Access Point Program Coordinator

Division of Policy and Development

HRSA, Bureau of Primary Health Care

5600 Fishers Lane, Mailstop 17-61

Rockville, MD 20857

Telephone: 301-594-4300

Fax: 301-594-4997

Email: <preeti.kanodia@hrsa.hhs.gov>

Technical assistance regarding this funding announcement may be obtained
by contacting the appropriate State PCA, PCO or National Organization.
Please see Attachment 4 (page
[126](#primary-care-association-primary-care-office)) of this guidance
for a listing.

# Other Information

## Technical Assistance Set-Aside {#technical-assistance-set-aside .unnumbered}

The changing health care environment demands that key health center
management staff including Chief Executive Directors, Chief Financial
Directors, Clinical Directors and Chief Information Officers, work
together as a team to develop a strong organizational structure and
processes designed to ensure the provision of high quality health care
services and the overall success of their project. Experience has proven
that organizations that start with these attributes have the highest
probability of being successful.

**Each NEW START applicant is encouraged to budget for and set-aside a
minimum of 2 percent of the expected award for technical assistance and
performance improvement activities.** Each new start organization that
is selected for funding will be scheduled for a site visit within 150
days of grant award to assist the grantee in identifying and
prioritizing areas of technical assistance. Successful new applicants
will be expected to submit a TA workplan and budget to their project
officer following this visit. Both the HRSA project officer and the PCA
contact are available to assist in identifying training and technical
assistance opportunities. Examples of areas of technical assistance and
training activities include administration; governance; managed care;
financial management; Management Information Systems (MIS); clinical
management; reengineering; and cluster clinical collaboratives.

## Federal Tort Claims Act Coverage/Medical Malpractice Insurance {#federal-tort-claims-act-coveragemedical-malpractice-insurance .unnumbered}

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). A
deemed health center must apply annually to continue to be deemed.

In order for its employees to be deemed, a health center must have
implemented policies and procedures that reduce the risk of malpractice
and have reviewed and verified the credentials of all licensed and
certified health care practitioners. All licensed or certified health
care practitioners must be credentialed and privileged before a health
center deeming application can be approved. Finally, the health center
must agree to fully cooperate with HRSA, HHS' Office of the General
Counsel, and the Department of Justice in defending any claims.

Organizations should be aware that participation in the FTCA program is
[not guaranteed]{.underline}. If a health center 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.

Organizations that are not currently FTCA deemed should include the
costs of appropriate malpractice insurance in the budget, as FTCA
deeming is not guaranteed**.** **Please note that FTCA deeming is a
SEPARATE application process from this funding opportunity.** If new
access point funding is received, the organization may submit an
application for FTCA deeming using PIN 99-08 (available online at:
http://www.bphc.hrsa.gov/pinspals/pinsarchive.htm).

Funded organization should send initial deeming applications to:

> HRSA Health Center FTCA Program
>
> Attn: Original Deeming Application Coordinator
>
> Bureau of Primary Health Care, HRSA
>
> 5600 Fishers Lane, Mailstop 17C-26
>
> Rockville, MD 20857
>
> Telephone: 301.594.2469
>
> Fax: 301.594.5224

The application must include:

1.  Application for Medical/Dental Professional Liability Protection --
    Federal Tort Claims Act (in PIN 99-08)

2.  First page of most recent notice of grant award (NGA)

3.  Form 5 -- Part A: Services Provided

4.  Form 5 -- Part B: Service Sites

5.  Form 5 -- Part C: Other Activities/Locations

6.  Updated staff list of licensed or certified health care providers
    based on PIN 2002-22: Credentialing and Privileging to include each
    provider's

    a.  name and clinical degree/designation

    b.  employment status (e.g., full time employee, part time employee,
        contractor, volunteer)

    c.  date of hire

    d.  initial credentialing/privileging date

    e.  last credentialing/privileging date

7.  Copy of the health center's board approved quality assurance plan to
    include the date it was approved by the board.

8.  State document indicating legal name change if the health center's
    name changed since its last deeming application was submitted

[]{.mark}

If an applicant seeking support is currently deemed, the organization
does not need to submit a new FTCA deeming application. If the
application is funded, the proposed project will be part of the
organization's approved scope of project and covered by their existing
deemed status.

For general information on this malpractice program please 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)
Monday thru Friday from 9 AM to 8 PM EST.

## 340b Drug Pricing Program {#b-drug-pricing-program .unnumbered}

Organizations that receive grant funds under section 330 of the PHS Act,
as amended, are eligible to purchase prescription and non-prescription
medications for their outpatients at reduced cost through the 340B Drug
Pricing Program. Grantees are not required to operate/own a pharmacy in
order to participate in this program. Given the pharmacist shortage
nationwide, grantees may want to consider contracting with a local
pharmacy. In order to participate in this program, a health center must
submit a Program Registration Form to the Office of Pharmacy Affairs,
Healthcare System Bureau, HRSA along with its Medicaid information.

For general information on the 340B program, please contact the Office
of Pharmacy Affairs at 800-628-6297 or visit the website at
http://bphc.hrsa.gov/opa.

# 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]{.underline}](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. 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. If the information
is not placed in the requested order, you may receive a lower score.

**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.

**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 located in the appendices to
the appropriate text in the application.

**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.

**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 accepted.

#  {#section .unnumbered}

#  {#section-1 .unnumbered}

#  {#section-2 .unnumbered}

# APPENDIX A: HRSA's Electronic Submission User Guide  {#appendix-a-hrsas-electronic-submission-user-guide .unnumbered}

# User Guide Table of Contents {#user-guide-table-of-contents .unnumbered}

1\.
INTRODUCTION\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....57

1.1. DOCUMENT PURPOSE AND
SCOPE\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....57

1.2. DOCUMENT ORGANIZATION AND VERSION
CONTROL\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...57

2\. NONCOMPETING CONTINUATION
APPLICATION\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....57

2.1. PROCESS
VERVIEW\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....57

2.2. GRANTEE ORGANIZATION NEEDS TO REGISTER WITH
[[GRANTS.GOV]{.underline}](http://GRANTS.GOV/) (IF NOT ALREADY
REGISTERED)..............................................................................\...\...\...\...\....58

2.3. PROJECT DIRECTOR AND AUTHORIZING OFFICIAL NEED TO REGISTER WITH
HRSA EHBS (IF NOT ALREADY REGISTERED)
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....59

2.4. APPLY THROUGH [[GRANTS.GOV]{.underline}](http://GRANTS.GOV/)
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....60

2.4.1 Find Funding
Opportunity\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...60

2.4.2 Download Application Package
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...60

2.4.3 Complete
Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....60

2.4.4 Submit
Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....60

2.4.5 Verify Status of Application
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.......61

2.5. VERIFY IN HRSA ELECTRONIC HANDBOOKS
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....61

2.5.1 Verify Status of Application
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....61

2.5.2 Manage Access to Your Application
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....62

2.5.3 Check Validation
Errors\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....62

2.5.4 Fix Errors and Complete
Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....62

2.5.5 Submit
Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....62

2.6. SUBMIT SIGNED FACE
PAGE\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...62

3\. COMPETING
APPLICATION\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...63

3.1. PROCESS
OVERVIEW\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....63

3.2. GRANTEE ORGANIZATION NEEDS TO REGISTER WITH
[[GRANTS.GOV]{.underline}](http://GRANTS.GOV/) NOT ALREADY
REGISTERED)\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....63

3.3. APPLY THROUGH
[[GRANTS.GOV]{.underline}](http://GRANTS.GOV/)\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...64

3.3.1 Find Funding
Opportunity\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...64

3.3.2 Download Application
Package\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....64

3.3.3 Complete
Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....64

3.3.4 Submit
Application\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....64

3.3.5 Verify Status of Application
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....65

3.4. SUBMIT SIGNED FACE PAGE
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....65

4\. GENERAL INSTRUCTIONS FOR APPLICATION
SUBMISSION\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....66

4.1. NARRATIVE ATTACHMENT
GUIDELINES\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....66

4.1.1
Font\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....66

4.1.2 Paper Size and
Margins\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....66

4.1.3
Names\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....66

4.1.4 Section Headings
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....66

4.1.5 Page
Numbering\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....66

4.1.6 Allowable Attachment or Document
Types\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....77

4.2. APPLICATION CONTENT ORDER (TABLE OF
CONTENTS)\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...77

4.3. PAGE
LIMIT\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....77

5.0 CUSTOMER SUPPORT INFORMATION
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....68

5.1.1 Grants.gov Customer
Support\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....68

5.1.2 HRSA Call
Center\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....68

5.1.3 HRSA Program
Support\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....68

6.0
FAQs\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...68

6.1.
SOFTWARE\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....68

6.1.1 What are the software requirements for using
Grants.gov?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....68

6.1.2 Why can\'t I download PureEdge Viewer onto my
machine?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....69

6.1.3 I have heard that Grants.gov is not Macintosh compatible. What do
I do if I use only a Mac?\...\...\...69

6.1.4 What are the software requirements for HRSA
EHBs?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....69

6.1.5 What are the system requirements for using HRSA EHBs on a
Macintosh computer?\...\...\...\...\...\...\...69

6.2. APPLICATION RECEIPT
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...70

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?..................\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....70

6.2.2 When do I need to submit my application?
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....70

6.2.3 What emails can I expect once I submit my application? Is email
reliable?\...\...\...\...\...\...\...\...\...\...\...\.....70

6.2.4 If a resubmission is required because of Grants.gov system
problems, will these be considered
\"late\"?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....71

6.3. APPLICATION
SUBMISSION\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....71

6.3.1 How can I make sure that my electronic application is presented in
the right order for objective
review?\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...71

6.4 GRANT.GOV
HELP\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....71

#   {#section-3 .unnumbered}

#  {#section-4 .unnumbered}

**1 Introduction**

1.  **Document Purpose and Scope**

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.

2.  **Document Organization and Version Control**

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**

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)

10. AO prints the application face page from HRSA EHBs (not Grants.gov),
    signs it and mails it to HRSA's Grant Application Center (GAC).

11. HRSA receives the signed face page and scans it into the system
    saving it with the electronic application.

**2.2 Grantee Organization Needs to Register With Grants.gov (if not
already registered) -- See Appendix B**

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)

    o Obtain a username and password from the Grants.gov Credential
    Provider

    o Register the username and password with Grants.gov

    o 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.

##  {#section-5 .unnumbered}

**2.3 Project Director and Authorizing Official Need to Register with
HRSA EHBs (if not already registered)**

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.

##  {#section-6 .unnumbered}

**2.4 Apply through Grants.gov**

**2.4.1 Find Funding Opportunity**

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 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 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**

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.

###  {#section-7 .unnumbered}

**2.4.5 Verify Status of Application**

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**

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**

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**

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**

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**

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**

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.

**2.6 Submit Signed Face Page**

After successful submission, the AO must print the face page of the
application from the HRSA EHBs, sign it and mail it to HRSA at the
address listed below:

HRSA Grants Application Center

Reference: Announcement Number: *\<Provide HRSA Announcement Number\>*

Reference: Grants.gov Tracking Number: *\<Provide Your Grants.gov
Tracking Number\>*

910 Clopper Road, Suite 155 South

Gaithersburg, MD 20878

The face page must be received by HRSA within **5** business days from
the date of submission in HRSA EHBs.

Once your signed face page is received by HRSA and saved with the
application, you will receive an email receipt of application from HRSA.

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

**3 Competing Application**

**3.1 Process Overview**

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>.

```{=html}
<!-- -->
```
12. When program guidance is available, search for the announcement in
    Grants.gov Apply (<http://www.grants.gov/Apply>).

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

14. 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.

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

16. 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.

17. AO prints the application face page from the local copy, signs it
    and mails it to HRSA's Grant Application Center (GAC).

18. HRSA receives the signed face page and scans it into the system
    saving it with the electronic application.

**3.2 Grantee Organization Needs to Register With Grants.gov (if not
already registered) -- See Appendix B**

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)

    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**

**3.3.1 Find Funding Opportunity**

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 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 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**

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**

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 <DGPClearances@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".

**3.4 Submit Signed Face Page**

After successful submission in Grants.gov, the AO must print the face
page of the application from Grants.gov, write the Grants.gov Tracking
Number in Federal Entity Identifier field (box 5a in SF424 or box 4 in
SF424 R&R), sign it and mail it to HRSA at the address listed below:

HRSA Grants Application Center

Reference: Announcement Number: *\<Provide HRSA Announcement Number\>*

Reference: Grants.gov Tracking Number: *\<Provide Your Grants.gov
Tracking Number\>*

910 Clopper Road, Suite 155 South

Gaithersburg, MD 20878

The face page must be received by HRSA within **5** business days from
the date of submission in Grants.gov.

Once your signed face page is received by HRSA and saved with the
application, you will receive an email receipt of application from HRSA.

**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**

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

**4.1.1 Font**

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**

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**

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**

Please put all section headings flush left in bold type.

**4.1.5 Page Numbering**

**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**

**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)**

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**

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**

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.

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

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

**5.1.2 HRSA Call Center**

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**

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**

**6.1.1 What are the software requirements for using Grants.gov?**

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?**

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?**

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?**

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?**

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**

**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?**

**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?**

**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?**

**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.

You will receive an additional email from HRSA once your signed face
page is received and processed. This email serves as the official
receipt for your application.

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.

You will receive an additional email from HRSA once your signed face
page is received and processed. This email serves as the official
receipt for your application.

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\"?**

**Competing Submissions:**

No. But you must **contact the Director of the Division of Grants
Policy** via email at <DGPClearances@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**

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

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**

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 {#appendix-b-registering-and-applying-through-grants.gov .unnumbered}

**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
[DGPClearances@hrsa.gov](../DGPClearances@hrsa.gov%20) 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: {#appendix-c .unnumbered}

####### GUIDELINES FOR THE BUDGET PRESENTATION, HEALTH CARE PLAN AND BUSINESS PLAN {#guidelines-for-the-budget-presentation-health-care-plan-and-business-plan .unnumbered}

## *GUIDELINES FOR COMPLETION OF THE BUDGET FORMS* {#guidelines-for-completion-of-the-budget-forms .unnumbered}

This section explains the requirements for developing and presenting a
budget as part of the application for Federal support under the
Consolidated Health Center Program.

Please complete Sections A, B, E, and F (if F is applicable) of PHS
5161-1: Standard Form (SF) 424A, and then provide a line item budget
using the budget categories in the SF 424A, Section B. The budget should
clearly indicate cost for each program. **All budgets should be prepared
for a 12-month period for Year 1, Year 2, and Year 3.** The budget
request must be based upon the funding cap detailed in Appendix D.

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.

## Instructions For The Completion Of Form 3: Income Analysis  {#instructions-for-the-completion-of-form-3-income-analysis .unnumbered}

**Projecting revenue should involve the following steps and must be
presented using the Income Analysis Worksheet (FORM 3) format for the
first year of funding requested.**

The Income Analysis Worksheet provides a format for presenting the
estimated non-federal revenues for the application budget. A narrative
budget justification should accompany the form and should fully describe
any information presented on this worksheet. The information presented
in the worksheet must be based on the current approved scope of project.
It may not include any grant funds from any pending supplemental grants
or other unapproved increases in capacity.

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

**Program Income** includes fees, premiums and third party
reimbursements received for the provision of health care services.
Program income is divided into two parts, Fee for Service revenues and
Managed Care or Capitated Rate Income.

**Other Income** is revenue from any non-section 330 source to support
the applicant's programs. Other income includes State, Local or Federal
grants and other local or private support. If this revenue provides
support for the provision of medical or support services, but is not
based upon charges for services delivered, it is not considered program
income. NOTE: for the purpose of this form, this budget and this
application, "Federal" funds refers only to section 330 resources. Funds
received from non-section 330 Federal sources are considered as "other
Federal" or "non-Federal."

The categories in the worksheet may not describe all categories of Fee
for Service revenue or Other Income sources needed to describe the
applicant's total income. If needed, applicants may add lines for each
revenue source. The categories presented may also be redefined in the
worksheet narrative as necessary to clearly identify revenue sources.

# *[REVENUE RECEIVED ON A FEE FOR SERVICE BASIS]{.underline}* {#revenue-received-on-a-fee-for-service-basis .unnumbered}

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

> **NOTE:** *Not all visits reported on this form are to be counted 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 billed
> or billable to first or third parties including individuals who, after
> the sliding discount, may pay little or none of the actual charge.*

2.  Column (b): Enter the average charge per encounter by payor
    category.

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

4.  Column (d): Enter the average adjustment to the average charge per
    encounter in column (b). A negative number reduces and a positive
    number increases the Net Charges calculated in column (e).
    Adjustments in column (d) include those related to:

```{=html}
<!-- -->
```
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 to/down to the negotiated
    FQHC or Prospective Payment System established reimbursement rate or
    the cost based reimbursement expected as a result of completion of a
    cost reimbursement report.

d)  Any other adjustments the applicant defines in the narrative to this
    worksheet.

```{=html}
<!-- -->
```
5.  Column (e): Enter the total Net Charges by payment source calculated
    as \[columns c-(a\*d)\].

6.  Column (f): 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%. Explain any rate greater than
    100%. Do not show sliding discount percentages here -- they are
    included above in column (d); do show the collection rate for actual
    direct patient billings.

7.  Column (g): Enter Projected income for each payor category
    calculated as (columns (e)\*(f)).

8.  Column (h): Enter the actual accrued income by payor category for
    the most recent 12- month period for which data are available. A
    significant increase or decrease in income should be explained in
    the narrative budget justification to this worksheet. Include in the
    narrative budget justification or show on the table the dates of the
    12 month period used.

##  {#section-8 .unnumbered}

## [REVENUE RECEIVED ON A CAPITATED BASIS]{.underline} {#revenue-received-on-a-capitated-basis .unnumbered}

1.  The Projected Gross Income (Budgeted Expected Program Income) is
    calculated using the information in the third, fourth and fifth
    columns in this section.

> a\. "Member months" are the number of member months for which the
> grantee/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.

b\. "Rate per member month" means the average capitation rate paid for
each month for all contracts of this type. It is understood that there
may be different rates for each contract.

> c\. "Risk Pool Adjustments" include any payment made by the HMO to the
> grantee 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.
>
> d\. "FQHC and Other Adjustments" includes any cost based wrap around,
> and should be explained in the narrative to the worksheet.
>
> e\. Projected gross income (Budgeted Expected Program Income) is
> calculated as: \[**(Members per month) X (Number of months for the
> budget period) X (rate per member month)\] + (risk pool adj. & FQHC
> and Other Adjustments) X (Collection Rate) = projected gross income
> (budgeted expected program income).**

2.  Applicants should use a narrative budget justification to the
    worksheet to explain each managed care or capitated rate program
    included in the budget. Provide the current number of enrollees and
    average per member per month (PMPM) payment in the current budget.

## [OTHER INCOME]{.underline} {#other-income .unnumbered}

Other Income includes a wide range of sources including, but not limited
to, fundraising, contributions, foundation grants, interest income,
contracts for services (e.g., to be the Medical Director of a nursing
home) etc. 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 based upon services provided, encounters or charges for
encounters.* Include the source and value of in-kind donations in this
description, including donated pharmaceuticals, such as samples. [Use
the narrative to itemize grants and amounts if there are multiple grants
for any given line.]{.underline}

*[TOTAL PROGRAM INCOME -- SUMMARY TABLES]{.underline}*

1.  The WORKSHEET SUMMARY table is a summary of the program income
    budget information presented in the previous sections. The
    information for the worksheet summary should combine the Encounters,
    Average Charge Per Encounter, Total Gross Charges, Adjustments to
    Charges, Adjustments for Uncollectables, and Budgeted Expected
    Program Income from the Fee For Service and Managed Care --
    Capitated Rate Income sections that are shown on Page 1 of 2. In
    addition you want to verify that the Estimated Program Income
    Allocation Total by type of 330 grant in this section aggress to the
    total Budgeted Expected Program Income.

2.  The ESTIMATED PROGRAM INCOME ALLOCATION table should be consistent
    with the information provided in the Funding Request Summary and PHS
    5161-1 Forms. The information provided in these forms will be used
    by the Division of Grants Management to determine the Estimated
    Program Income used on the Notice of Grant Award (NGA). The
    applicant should distribute in the amount of the BUDGET EXPECTED
    PROGRAM INCOME from the WORKSHEET SUMMARY table to the Health Center
    funding source for which Federal funding is requested in this
    application.

#######  {#section-9 .unnumbered}

###### SAMPLE PHS 5161-1: SF424a {#sample-phs-5161-1-sf424a .unnumbered}

OMB Approval No. 0348-0044

+---+---------------+------+-------+------+-------+--------+----------+
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| B |               |      |       |      |       |        |          |
| U |               |      |       |      |       |        |          |
| D |               |      |       |      |       |        |          |
| G |               |      |       |      |       |        |          |
| 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 | *     |        | \(g\)    |
|   |               |      | \(c\) |      | *\*** | \(f\)  |          |
|   |               |      |       | \    |       |        |          |
|   |               |      |       | (d\) | \(e\) |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 1 | **New Access  |      | \$0   | \$0  | >     | >      | > \$8    |
| \ | Point Year    |      |       |      |  \$55 |  \$7,4 | ,023,934 |
| . | 1**           |      |       |      | 0,000 | 73,934 |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 2 | **New Access  |      | \$0   | \$0  | >     | >      | > \$9    |
| \ | Point Year    |      |       |      |  \$43 |  \$9,0 | ,510,741 |
| . | 2**           |      |       |      | 9,699 | 71,042 |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 3 | **New Access  |      | \$0   | \$0  | >     | >      | > \$10   |
| \ | Point Year    |      |       |      |  \$47 |  \$9,5 | ,263,196 |
| . | 3**           |      |       |      | 5,690 | 82,506 |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 4 |               |      | \$0   | \$0  | > \$0 | > \$0  | > \$0    |
| \ |               |      |       |      |       |        |          |
| . |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 5 | TOTALS        |      |       |      |       |        |          |
| \ |               |      |       |      |       |        |          |
| . |               |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| * |               |      |       |      |       |        |          |
| * |               |      |       |      |       |        |          |
| 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** |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   |               | \    | \(2\) | \    | \(4\) |        |          |
|   |               | (1\) | *     | (3\) |       |        |          |
|   |               | **   | *Year | **   |       |        |          |
|   |               | Year | 2**   | Year |       |        |          |
|   |               | 1**  |       | 3**  |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | a\. Personnel | >    | > \   | >    |       |        |          |
|   |               |  \$4 | $5,42 |  \$5 |       |        |          |
|   |               | ,587 | 2,816 | ,500 |       |        |          |
|   |               | ,223 |       | ,000 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | b\. Fringe    | > \  | > \   | >    |       |        |          |
|   | Benefits      | $951 | $1,12 |  \$1 |       |        |          |
|   |               | ,849 | 5,234 | ,130 |       |        |          |
|   |               |      |       | ,000 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | c\. Travel    | >    | > \$3 | >    |       |        |          |
|   |               | \$25 | 5,010 | \$40 |       |        |          |
|   |               | ,432 |       | ,690 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | d\. Equipment | > \  | > \$0 | >    |       |        |          |
|   |               | $118 |       |  \$0 |       |        |          |
|   |               | ,000 |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | e\. Supplies  | >    | > \   | >    |       |        |          |
|   |               |  \$1 | $1,95 |  \$2 |       |        |          |
|   |               | ,452 | 2,300 | ,330 |       |        |          |
|   |               | ,940 |       | ,000 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | f\.           | > \  | >     | > \  |       |        |          |
|   | Contractual   | $326 |  \$39 | $425 |       |        |          |
|   |               | ,020 | 5,100 | ,000 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | g\.           | >    | > \$0 | >    |       |        |          |
|   | Construction  | \$32 |       |  \$0 |       |        |          |
|   | --            | ,000 |       |      |       |        |          |
|   | Alterati      |      |       |      |       |        |          |
|   | on/Renovation |      |       |      |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | h\. Other     | > \  | >     | > \  |       |        |          |
|   |               | $530 |  \$58 | $632 |       |        |          |
|   |               | ,470 | 0,281 | ,506 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | i\. Total     | >    | > \   | >    |       |        |          |
|   | Direct        |  \$8 | $9,51 | \$10 |       |        |          |
|   | Charges (sum  | ,023 | 0,741 | ,058 |       |        |          |
|   | of 6a‑6h)     | ,934 |       | ,196 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | j\. Indirect  | >    | > \$0 | >    |       |        |          |
|   | Charges       |  \$0 |       |  \$0 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
|   | k\. TOTALS    | >    | > \   | >    |       |        |          |
|   | (sum of 6i    |  \$8 | $9,51 | \$10 |       |        |          |
|   | and 6j)       | ,023 | 0,741 | ,058 |       |        |          |
|   |               | ,934 |       | ,196 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+
| 7 | Program       | >    | > \   | >    |       |        |          |
| \ | Income        |  \$5 | $6,95 |  \$7 |       |        |          |
| . |               | ,770 | 6,304 | ,537 |       |        |          |
|   |               | ,180 |       | ,506 |       |        |          |
+---+---------------+------+-------+------+-------+--------+----------+

Standard Form 424A (7-97)

\* Applicants are limited to the level of Federal funds identified in
Program Guidance. Prescribed by OMB Circular A-102

## *SAMPLE BUDGET* {#sample-budget .unnumbered}

This sample line-item budget is provided as a [broad
outline]{.underline}. The examples used in this sample are for
illustrative purposes only. Providing additional information and detail
is recommended to fully describe your proposal. **Any significant
changes in the costs of each object class from year 1 to year 2 and year
2 to year 3 should be fully explained and justified in the budget
narratives for years 1, 2, and 3. The impact on the Federal request
should be discussed.**

**REVENUE:** (From FORM 3 -- Income Analysis) [Year 1]{.underline} [Year
2]{.underline} [Year 3]{.underline}

**PATIENT SERVICE INCOME** \$5,770,180 \$6,956,042 \$7,537,506

(including Pharmacy)

**LOCAL & STATE GRANTS** \$1,253,500 \$1,565,000 \$1,700,000

(Break out by fund source)

**LOCAL FUNDING** \$450,254 \$550,000 \$550,000

**FEDERAL 330 GRANT** \$550,000 \$439,699 \$475,690

**OTHER FEDERAL FUNDING** \$0 \$0 \$0

(Break out by fund source)

**TOTAL: REVENUE \$8,023,934 \$9,510,741 \$10,263,196**

**EXPENSES:** [Year 1]{.underline} [Year 2]{.underline} [Year
3]{.underline}

**PERSONNEL**: (i.e., Salary and Wages)

See Personnel by Position \$4,587,223 \$5,422,816 \$5,500,000

and HC funding Source

**FRINGE BENEFITS**: Break out each

portion of Fringe Benefits: \$951,849 \$1,125,234 \$1,130,000

FICA

Retirement, etc.

**TOTAL: PERSONNEL & FRINGE \$5,539,072 \$6,548,050 \$6,730,000**

**TRAVEL:**

Providers CME (\$ per full-time equivalent (FTE)) \$ \$ \$

Nursing CME (\$ per FTE) \$ \$ \$

Other Professional CME (\$ per FTE) \$ \$ \$

Travel to meetings (\$ per attendees x \# of trips) \$ \$ \$

Executive Director (2 meetings)

Board Chair (2 meetings)

Management & Board \$ \$ \$

State and National Meetings \$ \$ \$

Other Board/Management Travel \$ \$ \$

Local Travel (# of trips @ organization's mileage rate) \$ \$ \$

> **TOTAL: TRAVEL \$ 25,432 \$ 35,010 \$ 45,690**

**EQUIPMENT:**

See attached Equipment Listing

**TOTAL: EQUIPMENT \$118,000 \$ 0 \$ 0**

**Expenses Continued:** [Year 1]{.underline} [Year 2]{.underline} [Year
3]{.underline}

**SUPPLIES:**

Office & Printing Supplies \$X.XX per encounter \$ \$ \$

Medical & Dental Records \$X.XX per encounter \$ \$ \$

Medical Supplies \$X.XX per encounter \$ \$ \$

Pharmacy Supplies including Drugs

Average per \# of Prescriptions \$ \$ \$

X-ray supplies Average per \# of X-rays \$ \$ \$

Laboratory supplies per average \# of procedures \$ \$ \$

Building and Maintenance Supplies per \# of sites \$ \$ \$

**TOTAL: SUPPLIES \$1,452,940 \$1,952,300 \$2,430,000**

**CONTRACTUAL** (Please describe with enough detail to justify the
costs)

"Patient Care Contracts"

Outside Reference Lab \$ \$ \$

XYZ Company for any tests that cannot be

Performed in house (Avg \# of procedures

X Avg Cost) \$ \$ \$

Outside Contract Pharmacies (describe)

(Avg \# of prescriptions X Avg Cost) \$ \$ \$

GYN/OB Contract with ABC Company

(Avg \# of Patients served X Avg Cost) \$ \$ \$

Ophthalmologist with RST Company

(Avg \# of patients @ Avg Cost) \$ \$ \$

Temporary Nursing Coverage

(Avg \# of days @ Avg Costs) \$ \$ \$

**Subtotal: Patient Care Contracts \$ \$ \$**

"Non-Patient Contracts"

Housekeeping Services with LMN Company

for \# of sites \$ \$ \$

Security Services with DEF Company for

\# of hours per site \$ \$ \$

Computer Maintenance Contract \$ \$ \$

**Subtotal: Non-Patient Contracts \$ \$ \$**

**TOTAL: CONTRACTUAL \$386,020 \$395,100 \$425,000**

**ALTERATION & RENOVATIONS**: (describe if applicable)

Alteration and renovation of unused building space for use as dental
operatories

**TOTAL: A&R** \$ **32,000** **\$0 \$0**

**OTHER**: [Year 1]{.underline} [Year 2]{.underline} [Year
3]{.underline}

Payroll Processing Services \$ \$ \$

Audit Services with JKL Company \$ \$ \$

Legal Fees with WXY Company fee per hour \$ \$ \$

Association Dues \$ \$ \$

Building Contents Insurance \$ \$ \$

Telephone Service \$ \$ \$

Answering Services \$ \$ \$

Postage \$ \$ \$

Utilities \$ \$ \$

Rent (describe \$XX per month per site) \$ \$ \$

Marketing/Outreach \$ \$ \$

Any special taxes (describe) \$ \$ \$

Technical Assistance \$ \$ \$

(describe in detail, but Federal funding

CANNOT be used for fees associated

with grant writing)

**TOTAL: OTHER \$530,470 \$580,281 \$632,506**

**TOTAL: ALL BUDGET \$8,023,934 \$ 9,510,741 \$10,263,196**

**EQUIPMENT:** [Year 1]{.underline} [Year 2]{.underline} [Year
3]{.underline}

4 exam tables (4 @ \$3,000) \$ 12,000 \$0 \$0

1 Medical X-Ray (1 @ \$17,800) \$ 17,800 \$0 \$0

4 Dental Units (4 @ \$ 4,500) \$ 18,000 \$0 \$0

4 Dental Chairs (4 @ \$4,000) \$ 16,000 \$0 \$0

1 Dental X-Ray (1 @ \$10,200) \$ 10,200 \$0 \$0

8 Stools (8 @ \$250) \$ 2,000 \$0 \$0

20 Handpieces (20 @ \$600) \$ 12,000 \$0 \$0

1 Developing Unit (1 @ \$2,000) \$ 2,000 \$0 \$0

8 PCs and related software (8 @ 3,500) \$ 28,000 \$0 \$0

###  {#section-10 .unnumbered}

**TOTAL ALL EQUIPMENT \$ 118,000 \$0 \$0**

## *DEVELOPING THE HEALTH CARE PLAN AND BUSINESS PLAN* {#developing-the-health-care-plan-and-business-plan .unnumbered}

The following components are intended for use in both the Health Care
and Business Plans. A sample format for both the Health Care and
Business Plans are provided below.

*Health Care Plan*

In general, this section should be used to outline goals and objectives
related to the identified community health needs/issues and quality
improvement activities discussed in the program narrative. The health
care plan goals and objectives should be *specific to the Federal
section 330 funding requested*. Fiscal, administrative, MIS and
leadership activities are, in general, described in the Business Plan.
However, clinically-related MIS, administrative or management issues may
also be described in the Health Care Plan.

In addition to the table format for the Health Care Plan, applicants
should summarize the major aspects of the Health Care Plan in an
accompanying narrative and include those issues that cannot be captured
in the table format, such as, managed care arrangements and their impact
on the organization or other factors that may have affected, or are
expected to affect, progress in either a positive or negative way. [The
two required health measures (see below) must be described in more
detail within the accompanying narrative.]{.underline} While there is no
required page limit, it is expected that the Health Care Plan and
accompanying narrative 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:

The Health Care Plan for **New Access Point applicants** should address
issues related to the entire scope of the project being proposed for
Federal section 330 support. Applicants are expected to address the
following in their Health Care Plan, as applicable:

-   Major health related goals and objectives for each of the life
    cycles to be served by the proposed project

```{=html}
<!-- -->
```
-   Improving performance, quality, and outcomes, e.g., quality
    improvement plan activities, Clinical Outcome Measures, Healthy
    People 2010 Objectives, Health Disparities Collaboratives, Health
    Plan Employer Data and Information Set (HEDIS) measures,
    accreditation standards, Relative Value Units.

-   Eliminating Health Disparities as appropriate for the target
    community/population, e.g., infant mortality, adult and pediatric
    immunizations, diabetes mellitus, obesity cardiovascular disease,
    HIV infection, cancer prevention, asthma, hypertension.

-   Retention and recruitment of qualified staff.

-   Implementation of any type of quality improvement, and description
    of sustaining and spreading the quality improvement activities.

[]{.mark}

Organizations that have successfully completed a Health Disparities
Collaborative or implemented any type of quality improvement program
should indicate how such activities will improve clinical quality. For
more information about the Health Disparities Collaboratives and other
quality improvement activities, please visit
[http://www.healthdisparities.net](http://www.healthdisparities.net/).

[]{.mark}

*Required Health Care Plan Measures \--* NAP applicants are required to
incorporate two health care plan measures:

-   Immunization(s) ; and

-   Chronic disease condition(s) listed in the table below.

**List of Required and Optional Chronic Disease Health Measures**

+---------+---------------------------------------------------+--------+
| *       | **Description**                                   | **Re   |
| *Health |                                                   | quired |
| Me      |                                                   | or     |
| asure** |                                                   | Opti   |
|         |                                                   | onal** |
+---------+---------------------------------------------------+--------+
| > Immun | Percent of patients with appropriate              | > Re   |
| ization | immunizations documented -- by age & risk group   | quired |
|         | per guidelines:                                   | > --   |
|         |                                                   | >      |
|         | a\. **Children**: by age 2 years (19--35 months)  | Choose |
|         | with 4xDTaP, 3xIPV, 1xMMR, 3xHib, 3xHepB =        | > at   |
|         | "43133" (measure is "43133"; however complete     | >      |
|         | series by age 2 also includes: Varicellax1;       |  least |
|         | PCVx4; and may be Hibx4).                         | > one  |
|         |                                                   | > of   |
|         | b\. **Adolescent**: 13years of age with second    | > the  |
|         | MMR, completion of HepBx3, Td booster and         | > five |
|         | Varicella.                                        | > sp   |
|         |                                                   | ecific |
|         | c\. **Adult**: 50-64 years of age with annual     | > mea  |
|         | seasonal influenza vaccine during prior influenza | sures. |
|         | season.                                           |        |
|         |                                                   |        |
|         | d\. **Geriatric**: ≥ 65 years of age with a       |        |
|         | documented pneumococcal vaccination x1 after 65,  |        |
|         | and annual seasonal influenza vaccination during  |        |
|         | prior influenza season.                           |        |
|         |                                                   |        |
|         | > e\. **HIV/AIDS**: documented pneumococcal       |        |
|         | > vaccine, influenza vaccine, completed Hepatitis |        |
|         | > Ax2 & Hepatitis Bx3 vaccinations.               |        |
+---------+---------------------------------------------------+--------+
| >       | > Percentage of children 5 through 18 years of    | Re     |
|  Asthma | > age diagnosed with "persistent" asthma, who     | quired |
|         | > were prescribed appropriate medications.        | --     |
|         |                                                   | Choose |
|         |                                                   | at     |
|         |                                                   | least  |
|         |                                                   | one of |
|         |                                                   | the    |
|         |                                                   | six    |
|         |                                                   | sp     |
|         |                                                   | ecific |
|         |                                                   | mea    |
|         |                                                   | sures. |
+---------+---------------------------------------------------+--------+
| >       | > Percentage of adults diagnosed with an abnormal |        |
| Cardiov | > lipid profile, whose levels are under control.  |        |
| ascular |                                                   |        |
| >       |                                                   |        |
| disease |                                                   |        |
+---------+---------------------------------------------------+--------+
| >       | > Percentage of adults diagnosed with             |        |
| Cardiov | > hypertension, whose blood pressure is under     |        |
| ascular | > control.                                        |        |
| >       |                                                   |        |
| disease |                                                   |        |
+---------+---------------------------------------------------+--------+
| >       | > Percentage of adults with abnormal (a-breast OR |        |
|  Cancer | > b-cervical OR c-colon) cancer screening         |        |
|         | > results, for which referral and/or treatment    |        |
|         | > has been initiated within 30 days of test       |        |
|         | > completion.                                     |        |
+---------+---------------------------------------------------+--------+
| > D     | > Percentage of adults with type 1 or type 2      |        |
| iabetes | > diabetes, whose last HbA1c \< 7 %.              |        |
+---------+---------------------------------------------------+--------+
| >       | > Percentage of patients (a-children &            |        |
| Obesity | > adolescents OR b-adults) with a Body Mass Index |        |
|         | > indicating overweight or obesity, who have      |        |
|         | > received healthy weight counseling and/or other |        |
|         | > related interventions or treatment.             |        |
+---------+---------------------------------------------------+--------+

Selection of one of the chronic disease measure should be related to the
health problems significantly affecting the population served, as
evidenced in the Need section of Program Narrative. For both the
immunization and chronic disease measure, applicants will be required to
develop a one paragraph narrative addressing the following:

-   A measureable goal to be achieved within the 3 year project period.

-   Baseline data or plans to establish baseline data in the first year
    of the proposed project.

-   Anticipated percentage to be achieved by the end of year 2 (at full
    operational capacity).

Please do not include description of key action steps, personnel
involved or other comments within the Health Care Plan narrative.

Successful applicants will be required to report measurable progress on
the immunization and chronic disease measures in subsequent continuation
applications. Baseline data will be derived from currently established
management information systems. For more information, including
background, and suggestions for operationalizing the measures (suggested
numerators and denominators), please visit the HRSA website at:
<http://www.hrsa.gov/performancereview/>

*Business Plan*

All NAP applicants should use this section to outline goals and
objectives in the areas of administration, governance, finance, and
MIS*.* The Business Plan should be consistent with applicable program
specific guidances and HRSA program expectations and indicate how the
goals and objectives of the health center organization are tied into the
overall operational business goals of the organization.

In addition to the table format for the Business Plan, applicants may
summarize the major aspects of the plan in a accompanying narrative and
include those issues that cannot be captured in the table format, such
as, audit conditions or exceptions as identified in the most recent
report; managed care arrangements and their impact on the organization;
and any other factors that may have affected, or are expected to affect,
progress for implementing the service expansion project in either a
positive or negative way.

The Business Plan for **New Access Point applicants** should address
issues related to the entire scope of the project being proposed for
Federal section 330 support. The Business Plan should be formatted in
the categories of Administrative, Governance, Fiscal, and MIS.
Applicants are expected to address the following issues, as applicable,
in the Business Plan:

-   Start-up plans for achieving full operational capacity.

-   Recruitment and Retention of key management and other staff

-   Network development in a managed care environment.

-   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 related to the proposed project.

-   Governance issues/changes necessary.

*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. The
problem/need statements should tie into and flow from the overall
project description and the identified needs of the target
population(s). 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 and
express a sense of a desired future state or direction. Goals should
address identified needs or problems and are usually long-term (1 year
or more). An example of a measurable HCP goal is: *"To increase the
percent of pregnant users beginning prenatal care in the first trimester
of pregnancy from **49%** of the patient population to **85%** of the
patient population served by the health center within **5 years**."*
Applicants are expected to maintain the project period goal throughout
the entire approved project period**.**

Objectives are descriptions of desired, measurable, time‑limited results
or outcomes and are usually short term (1 year or less). Objectives
(intended results or outcomes) are measures of progress towards a goal.
They can be used to identify an acceptable level of performance or
establish criteria for evaluation. An example of a measurable HCP
objective is: *"To increase the percent of pregnant users beginning
prenatal care in the first trimester of pregnancy from **49%** of the
patient population to **52%** of the patient population served by the
health center within **12 months**."* Applicants are expected to report
progress achieved on the objectives in the subsequent budget period
renewal application**.** Use an upper case letter (A\...) for each goal
and list corresponding objectives by number (1\...).

**Column 2: Key Action Steps** - the major activities that must occur to
accomplish an objective critical actions that must be taken to attain
the measurable outcome or end result. Reference each action step by
corresponding upper case letter for goal, number for objective, and
lower case letter for action step (i.e., A.1.a.).

**Column 3: Expected Outcome** - action steps to be taken towards an
objective; quantifiable documented outcomes to be achieved. This column
must be completed for each objective. Reference each action step in the
same manner as above for Key Action Steps.

**Column 4: Data, Evaluation, & Measurement** - the source of data,
evaluation method and measurement used to evaluate progress towards an
objective or to identify the actual outcome distinguished in the
objective. Reference each action step in the same manner as above for
Key Action Steps. Measures should be based on valid and reliable data
derived from currently established health center management information
systems.

**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. Reference each action step in the same manner as above for
Key Action Steps.

.

###### Sample Format for the Health Care Plan & Business Plan Presentations {#sample-format-for-the-health-care-plan-business-plan-presentations .unnumbered}

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:

+-----------+-------------+--------------+----------+--------+-------+
| Pro       |             |              |          |        |       |
| blem/Need |             |              |          |        |       |
| S         |             |              |          |        |       |
| tatement: |             |              |          |        |       |
| Diabetes  |             |              |          |        |       |
| is a      |             |              |          |        |       |
| common    |             |              |          |        |       |
| diagnosis |             |              |          |        |       |
| among     |             |              |          |        |       |
| patients  |             |              |          |        |       |
| of CHC,   |             |              |          |        |       |
| Inc. CHC, |             |              |          |        |       |
| Inc. aims |             |              |          |        |       |
| to        |             |              |          |        |       |
| improve   |             |              |          |        |       |
| care and  |             |              |          |        |       |
| quality   |             |              |          |        |       |
| of life   |             |              |          |        |       |
| for its   |             |              |          |        |       |
| clients   |             |              |          |        |       |
| with      |             |              |          |        |       |
| diabetes  |             |              |          |        |       |
| by        |             |              |          |        |       |
| re        |             |              |          |        |       |
| designing |             |              |          |        |       |
| the       |             |              |          |        |       |
| delivery  |             |              |          |        |       |
| of health |             |              |          |        |       |
| care      |             |              |          |        |       |
| services. |             |              |          |        |       |
+-----------+-------------+--------------+----------+--------+-------+
| Goals/O   | Key Action  | Expected     | Data,    | Perso  | Com   |
| bjectives | Steps       | Outcome      | Ev       | n/Area | ments |
|           |             |              | aluation | Respo  |       |
|           |             |              | &        | nsible |       |
|           |             |              | Mea      |        |       |
|           |             |              | surement |        |       |
+-----------+-------------+--------------+----------+--------+-------+
| A. To     | A.1.(a)     | A.1.(a) By   | A.1(a)   | A      | A.    |
| improve   | Track       | 5/06, 90% of | Medical  | .1.(a) | 1.(a) |
| the       | patients to | patients     | Records  | N      | He    |
| health    | insure they | have had a   |          | ursing | althy |
| status of | have annual | retinal eye  | A.1(b)   | Staff  | P     |
| patients  | retinal eye | exam in the  | Data,    |        | eople |
| with      | exams and   | last 12 mts  | Eval &   | A      | 2010  |
| diabetes  | foot exams. |              | Meas     | .1.(b) | Goals |
|           | Refer as    | A.1.(b)      |          | Perso  | and   |
| A.1. At   | needed      | Expected     | A.1.(c)  | n/Area | Obj   |
| least 90% |             | Outcome      | Data,    |        | (5-1  |
| of        | A.1 (b)     |              | Eval &   | A      | th    |
| patients  | Action step | A.1.(c)      | Meas     | .1.(c) | rough |
| will have | 2 for       | Expected     |          | Perso  | 5     |
| had a     | Objective 1 | Outcome      | A.2.(a)  | n/Area | -17). |
| retinal   |             |              | Data,    |        |       |
| eye exam  | A.1.(c)     | A.2.(a)      | Eval &   | A      | A.    |
| in the    | Action step | Expected     | Meas     | .2.(a) | 1.(b) |
| last 12   | 3 for       | Outcome      |          | Perso  | Com   |
| months by | Objective 1 |              | A.2.(b)  | n/Area | ments |
| 5/06      |             | A.2.(b)      | Data,    |        |       |
|           | A.2.(a)     | Expected     | Eval     | A      | A.    |
| A.2.      | Action step | Outcome      | &Meas    | .2.(b) | 1.(c) |
| Objective | 1 for       |              |          | Perso  | Com   |
| (2)       | Objective 2 |              |          | n/Area | ments |
|           |             |              |          |        |       |
|           | A.2 (b)     |              |          |        | A.    |
|           | Action step |              |          |        | 2.(a) |
|           | 2 for       |              |          |        | Com   |
|           | Objective 2 |              |          |        | ments |
|           |             |              |          |        |       |
|           |             |              |          |        | A.    |
|           |             |              |          |        | 2.(b) |
|           |             |              |          |        | Com   |
|           |             |              |          |        | ments |
+-----------+-------------+--------------+----------+--------+-------+
| Pro       |             |              |          |        |       |
| blem/Need |             |              |          |        |       |
| S         |             |              |          |        |       |
| tatement: |             |              |          |        |       |
| Wel       |             |              |          |        |       |
| l-managed |             |              |          |        |       |
| human     |             |              |          |        |       |
| resources |             |              |          |        |       |
| are       |             |              |          |        |       |
| critical  |             |              |          |        |       |
| to the    |             |              |          |        |       |
| success   |             |              |          |        |       |
| of any    |             |              |          |        |       |
| orga      |             |              |          |        |       |
| nization. |             |              |          |        |       |
+-----------+-------------+--------------+----------+--------+-------+
| B.        | B.1.(a)     | B.1.(a) Exam | B.1.(a)  | B      | B.    |
| Maintain  | Each exam   | rooms        | List of  | .1.(a) | 1.(a) |
| well-     | room will   | properly     | exam     | CQI    | Com   |
| qualified | be fully    | equipped     | room     | Team   | ments |
| staff for | equipped    |              | eq       | and    |       |
| health    | for all     | B.1.(b)      | uipment. | staff  | B.    |
| center.   | aspects of  | Expected     |          |        | 1.(b) |
|           | patient     | Outcome      | B.1.(b)  | B      | Com   |
| B.1.      | care.       |              | Data,    | .1.(b) | ments |
| Implement |             | B.2.(a)      | Ev       | Perso  |       |
| an annual | B.1 (b)     | Expected     | aluation | n/Area | B.    |
| pe        | Action step | Outcome      | &        |        | 2.(a) |
| rformance | 2 for       |              | Mea      | B      | Com   |
| e         | Objective 1 | B.2.(b)      | surement | .2.(a) | ments |
| valuation |             | Expected     |          | Perso  |       |
| and       | B.2.(a)     | Outcome      | B.2.(a)  | n/Area | B.    |
| employee  | Action step |              | Data,    |        | 2.(b) |
| sat       | 1 for       |              | Ev       | B      | Com   |
| isfaction | Objective 2 |              | aluation | .2.(b) | ments |
| program.  |             |              | &        | Perso  |       |
|           | B.2 (b)     |              | Mea      | n/Area |       |
| B.2.      | Action step |              | surement |        |       |
| Objective | 2 for       |              |          |        |       |
| (2)       | Objective 2 |              | B.2.(b)  |        |       |
|           |             |              | Data,    |        |       |
| B.3.      |             |              | Ev       |        |       |
| Objective |             |              | aluation |        |       |
| (3)       |             |              | &        |        |       |
|           |             |              | Mea      |        |       |
|           |             |              | surement |        |       |
+-----------+-------------+--------------+----------+--------+-------+
| C. Goal   | C.1.(a)     | C.1.(a)      | C.1.(a)  | C      | C.    |
|           | Action step | Expected     | Data,    | .1.(a) | 1.(a) |
| C.1.      | 1 for       | Outcome      | Ev       | Perso  | Com   |
| Objective | Objective 2 |              | aluation | n/Area | ments |
| (1)       |             | C.1.(b)      | &        |        |       |
|           | C.1 (b)     | Expected     | Mea      | C      | C.    |
|           | Action step | Outcome      | surement | .1.(b) | 1.(b) |
|           | 2 for       |              |          | Perso  | Com   |
|           | Objective 2 |              | C.1.(b)  | n/Area | ments |
|           |             |              | Data,    |        |       |
|           |             |              | Ev       |        |       |
|           |             |              | aluation |        |       |
|           |             |              | &        |        |       |
|           |             |              | Mea      |        |       |
|           |             |              | surement |        |       |
+-----------+-------------+--------------+----------+--------+-------+

####### Appendix D: Program Specific Forms {#appendix-d-program-specific-forms .unnumbered}

PLEASE REFER TO PAGE [29](#_Ref143938736) UNDER "PROGRAM SPECIFIC FORMS"
FOR MORE INFORMATION

##### FORM 1 -- Part A: GENERAL INFORMATION WORKSHEET - FY 2007 {#form-1-part-a-general-information-worksheet---fy-2007 .unnumbered}

<table>
<colgroup>
<col style="width: 7%" />
<col style="width: 12%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 10%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14">Applicant Name:      </td>
<td colspan="14">Name of Contact Person:      </td>
</tr>
<tr class="even">
<td colspan="14">Street Address:      </td>
<td colspan="14">Title:      </td>
</tr>
<tr class="odd">
<td colspan="14">City, State, Zip:      </td>
<td colspan="14">Email:      </td>
</tr>
<tr class="even">
<td colspan="14">Phone:      </td>
<td colspan="14">Fax:      </td>
</tr>
<tr class="odd">
<td colspan="28">Proposed Service Area (City, County, State):      </td>
</tr>
<tr class="even">
<td colspan="28">Relevant ZIP CODES for proposed service area:
     </td>
</tr>
<tr class="odd">
<td colspan="28">Relevant CENSUS TRACTS for proposed service area:
     </td>
</tr>
<tr class="even">
<td colspan="28"></td>
</tr>
<tr class="odd">
<td colspan="28"><strong>Please Check ONE on each line:</strong></td>
</tr>
<tr class="even">
<td colspan="11"> PRIVATE NONPROFIT</td>
<td colspan="17"> PUBLIC ENTITY</td>
</tr>
<tr class="odd">
<td colspan="11"> NEW START</td>
<td colspan="17"> SATELLITE (UDS #: <u>)</u></td>
</tr>
<tr class="even">
<td colspan="11"> MEDICALLY UNDERSERVED AREA</td>
<td colspan="13"> MEDICALLY UNDERSERVED POPULATION</td>
<td colspan="4"> N/A</td>
</tr>
<tr class="odd">
<td colspan="2"> URBAN</td>
<td colspan="9"> RURAL</td>
<td colspan="17"> SPARSELY POPULATED/FRONTIER (persons/
mile<sup>2</sup>: <u>)</u></td>
</tr>
<tr class="even">
<td colspan="28"><strong>Please check ALL that apply:</strong></td>
</tr>
<tr class="odd">
<td colspan="5"> Tribal Entity/Urban Indian</td>
<td colspan="5"> Public Health Dept</td>
<td colspan="6">Hospital</td>
<td colspan="4"> University</td>
<td colspan="5"> Faith-based Organization</td>
<td colspan="3"> Local Govt</td>
</tr>
<tr class="even">
<td colspan="28"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"><strong>TOTAL Federal Funding Requested</strong></td>
<td colspan="5"><strong>TOTAL ONE-TIME FUNDS</strong> (included in Yr 1
Federal Funds Requested)</td>
<td colspan="6"><strong>TOTAL PROJECT BUDGET</strong></td>
<td colspan="2" rowspan="4"></td>
<td colspan="11" rowspan="2"><p><strong>FEDERAL FUNDING
REQUESTED:</strong></p>
<p>Applicants should indicate section 330 funding requested above by
placing an “X” in the appropriate box(es). (May request more than one
type.) The types indicated above should coincide with the funding
request on Form 1, Part B.</p></td>
</tr>
<tr class="even">
<td><strong>Year 1</strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="odd">
<td><strong>Year 2</strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="5"><mark></mark></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="4">CHC</td>
<td>MHC</td>
<td colspan="4">HCH</td>
<td colspan="2">PHPC</td>
</tr>
<tr class="even">
<td><strong>Year 3</strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="5"><mark></mark></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="4"></td>
<td></td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="28"></td>
</tr>
<tr class="even">
<td colspan="28"><strong><u>GENERAL INFORMATION:</u> New start
applicants</strong> proposing one or more delivery sites should report
combined data for all of the sites to be included under the scope of
project. <strong>Satellite applicants</strong> should provide data for
the proposed NEW ACCESS POINT(S) ONLY. If a site(s) is already
operational, report the current number of users/encounters with the
projected number of users and encounters after 2 years of operation. If
the site(s) is not operational, report current number as “0”.
<strong>Data reported should be unduplicated for users and
encounters.</strong></td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td colspan="5">CURRENT NUMBER</td>
<td colspan="6">Projected at FULL CAPACITY</td>
<td colspan="5">UNDUPLICATED COUNTS</td>
<td colspan="4">CURRENT NUMBER</td>
<td>Projected at FULL CAPACITY</td>
</tr>
<tr class="even">
<td colspan="7">Total SERVICE AREA POPULATION</td>
<td colspan="5">     </td>
<td colspan="6"></td>
<td colspan="5">Medical Users</td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="7">Total TARGET POPULATION</td>
<td colspan="5">     </td>
<td colspan="6"></td>
<td colspan="5">Medical Encounters</td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="7">Total number of USERS</td>
<td colspan="5">     </td>
<td colspan="6">     </td>
<td colspan="5">Dental Users</td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="7">Total number of ENCOUNTERS</td>
<td colspan="5">     </td>
<td colspan="6">     </td>
<td colspan="5">Dental Encounters</td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="7">TOTAL FTE Medical Providers (Physicians, Nurse
Practitioners, Physicians Assistants, etc.)</td>
<td colspan="5">     </td>
<td colspan="6">     </td>
<td colspan="5">Mental Health Users</td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="7">TOTAL FTE Dental Providers (Dentists and
hygienists)</td>
<td colspan="5">     </td>
<td colspan="6">     </td>
<td colspan="5">Mental Health Encounters</td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="7">TOTAL FTE Mental Health Providers (Psychiatrists,
psychologists, MSWs, etc.)</td>
<td colspan="5">     </td>
<td colspan="6">     </td>
<td colspan="5">Substance Abuse Service Users</td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="7">TOTAL FTE Substance Abuse Service Providers</td>
<td colspan="5">     </td>
<td colspan="6">     </td>
<td colspan="5">Substance Abuse Service Encounters</td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="28"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3">CURRENT USER NUMBER</td>
<td colspan="2">NUMBER AFTER 1 YEAR</td>
<td colspan="5">NUMBER AFTER 2 YEARS</td>
<td colspan="5">NUMBER AT FULL CAPACITY</td>
<td rowspan="6"></td>
<td colspan="9"><strong>PREFERENCE REQUEST</strong></td>
</tr>
<tr class="even">
<td colspan="3">General Community</td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4" rowspan="5"><p>Service Area is Sparsely Populated:
(persons/mile<sup>2</sup>:<u>    )</u></p>
<p><em>Must provide evidence that ENTIRE NAP Service Area is sparsely
populated (e.g., Census Bureau documentation)</em></p></td>
<td colspan="4">Yes</td>
<td>No</td>
</tr>
<tr class="odd">
<td colspan="3">Migrant/Seasonal Farmworkers</td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="5">     </td>
<td colspan="5">     </td>
<td colspan="4" rowspan="4"></td>
<td rowspan="4"></td>
</tr>
<tr class="even">
<td colspan="3">Public Housing Residents</td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="5">     </td>
<td colspan="5">     </td>
</tr>
<tr class="odd">
<td colspan="3">Homeless Persons</td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="5">     </td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="3">TOTAL</td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="5">     </td>
<td colspan="5">     </td>
</tr>
</tbody>
</table>

![](media/image1.wmf){width="1.4618055555555556in" height="0.23125in"}

######## **Helpful Hints in Completing Form 1 -- Part A: GENERAL INFORMATION WORKSHEET** {#helpful-hints-in-completing-form-1-part-a-general-information-worksheet .unnumbered}

Form 1 -- Part A: General Information Worksheet provides a summary of
information related to the proposed budget, Health Care and Business
Plans, user/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.

**All forms, including Form 1- Part A, MUST be consistent with the
information discussed in the program narrative on the funding cap,
service area, target population.**

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

-   Select the Proposed Service Area City/State.

-   List all of the zip codes and census tracts proposed to be served.

-   Do not include zip codes and/or census tracts representing patients
    that may receive services from the health center but are outside the
    health center's service area. Please refer the definition of service
    area found in Appendix F of the guidance under "Definitions".

-   Information to determine the census tract(s) within a given service
    area may be found on page Appendix F of the guidance under "New
    Access Point Definitions."\
    \
    [**ORGANIZATION TYPE**:]{.underline}

```{=html}
<!-- -->
```
-   Please select the organization type (s) which best describes your
    health center. Eligible applicants may be either a private
    non-profit or a public entity.

**[SERVICE AREA TYPE:]{.underline}**

-   Select the designation(s) and or descriptors (urban, rural, and/or
    sparsely populated) which best describe the health center's approved
    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 shortage designations, 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/>.

**[FUNDING REQUESTED:]{.underline}**

-   The maximum level of Federal Funding for each year CANNOT exceed
    \$650,000. The one-time funding request allowed CANNOT exceed
    \$150,000 and must be calculated as part of the total Federal
    Funding requested in Year 1. Please do not make additional
    calculations for anticipated awards, rescissions, and/or base
    adjustments.

**[GENERAL INFORMATION:]{.underline}**

-   For this section, applicants with more than one proposed delivery
    site should report aggregate data for all of the sites included in
    the proposed new access point..

-   New start applicants proposing one or more delivery sites should
    report combined data for all of the sites to be included under the
    scope of project. Satellite applicants should provide data for the
    proposed NEW ACCESS POINT(S) ONLY. If a site(s) is already
    operational, report the current number of users/encounters with the
    projected number of users and encounters after 2 years of operation.
    If the site(s) is not operational, report current number as "0".
    Data reported should be unduplicated for users and encounters.

-   For Form 1 -- Part A, "current" refers to the number of users and/or
    encounters served by the new access point at the time of
    application. "Proposed" refers to the number of users and/or
    encounters by the health center at full operational capacity.

**[PREFERENCE REQUEST]{.underline}**

-   Sparsely Populated preference may only be requested if the ENTIRE
    proposed new access point service area is sparsely populated

-   If a preference is requested, evidence (e.g., Census Bureau or State
    documentation) for ENTIRE proposed service area must be submitted

##### FORM 1 -- Part B: FUNDING REQUEST SUMMARY {#form-1-part-b-funding-request-summary .unnumbered}

> **New access point applicants may request funding for one or more
> types of health centers authorized under section 330. Applicants
> should indicate what portion of the total Federal funding requested in
> each of the three years, is being requested under any or all of the
> program types below. The funding requested should correspond to what
> is indicated on Form 1-Part A. The specified types of health centers
> on this form will constitute a request for funding under that section
> 330 program.** NOTE: The Federal support requested in Year 1, 2, 3 MAY
> NOT exceed the published cap of \$650,000 established for new access
> point.

<table>
<colgroup>
<col style="width: 19%" />
<col style="width: 12%" />
<col style="width: 4%" />
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 3%" />
<col style="width: 14%" />
<col style="width: 13%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><strong>FEDERAL FUNDS REQUESTED: BASED ON A 12-MONTH
BUDGET FOR YEAR 1, YEAR 2 OR YEAR 3</strong></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="4"><strong>YEAR 1</strong></td>
<td><strong>YEAR 2</strong></td>
<td><strong>YEAR 3</strong></td>
</tr>
<tr class="odd">
<td colspan="2"><p><strong>REQUESTED FUNDING SOURCE</strong></p>
<p>May request funding under more than<br />
one section 330 program</p></td>
<td colspan="2"><p><strong>Program</strong></p>
<p>(section 330 authority)</p></td>
<td colspan="2"><strong>Operational</strong></td>
<td colspan="2"><p><strong>One-Time</strong></p>
<p><strong>(up to $150,000)</strong></p></td>
<td><strong>Operational</strong></td>
<td><strong>Operational</strong></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Community Health Center</strong></td>
<td colspan="2"><strong>CHC – 330(e)</strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td><strong>     </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Migrant Health Center</strong></td>
<td colspan="2"><strong>MHC – 330(g)</strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td><strong>     </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Health Care for the Homeless</strong></td>
<td colspan="2"><strong>HCH – 330(h)</strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td><strong>     </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Public Housing Primary Care</strong></td>
<td colspan="2"><strong>PHPC – 330(i)</strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td><strong>     </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="4"><p><strong>TOTAL NEW ACCESS POINT FEDERAL FUNDING
REQUEST</strong></p>
<p>(cannot exceed $650,000 in any year)</p></td>
<td colspan="4"><strong>     </strong></td>
<td><strong>     </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>ESTIMATED TOTAL NEW ACCESS POINT PROJECT
BUDGET:</strong></td>
</tr>
<tr class="even">
<td><strong>FUNDING PROGRAM:</strong></td>
<td colspan="2"><p><strong>YEAR 1</strong></p>
<p><strong>TOTAL BUDGET</strong></p></td>
<td colspan="2"><p><strong>YEAR 2</strong></p>
<p><strong>TOTAL BUDGET</strong></p></td>
<td colspan="2"><p><strong>YEAR 3</strong></p>
<p><strong>TOTAL BUDGET</strong></p></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td><strong>A. Federal</strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td><strong>B. Applicant</strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td><strong>C. State</strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td><strong>D. Local</strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td><strong>E. Other</strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td><strong>F. Program Income</strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td><strong>G. Total</strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"></td>
</tr>
</tbody>
</table>

![](media/image1.wmf){width="1.4618055555555556in" height="0.23125in"}

##### FORM 2: PROPOSED STAFF PROFILE {#form-2-proposed-staff-profile .unnumbered}

**YEAR 1 YEAR 2 YEAR 3**

+-------------------------+---------+------------+---------+---------+
| **PERSONNEL BY          | **      | **TOTAL    | ANNUAL  | TOTAL   |
| CATEGORY**              | CURRENT | FTEs       | SALARY  | SALARY  |
|                         | STA     | PROPOSED** | OF      |         |
|                         | FFING** |            | P       | { a \*  |
|                         |         | **{ a }**  | OSITION | b }     |
|                         |         |            |         |         |
|                         |         | NEW        | { b }   |         |
|                         |         | STARTS -   |         |         |
|                         |         | Staff for  |         |         |
|                         |         | all sites  |         |         |
|                         |         | on Form 5  |         |         |
|                         |         | -- Part B  |         |         |
|                         |         |            |         |         |
|                         |         | SA         |         |         |
|                         |         | TELLITES - |         |         |
|                         |         | Staff for  |         |         |
|                         |         | new access |         |         |
|                         |         | points(s)  |         |         |
|                         |         | ONLY       |         |         |
+-------------------------+---------+------------+---------+---------+
| **ADMINISTRATION**      |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| > Executive Director /  | **      | **     **  | **      | **      |
| > CEO                   |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Finance Director /    | **      | **     **  | **      | **      |
| > CEO (Fiscal Officer)  |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Chief Operating       | **      | **     **  | **      | **      |
| > Officer               |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Chief Information     | **      | **     **  | **      | **      |
| > Officer               |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Administrative        | **      | **     **  | **      | **      |
| > Support Staff         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| **MEDICAL STAFF**       |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| > Medical/Clinical      | **      | **     **  | **      | **      |
| > Director              |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Family Practitioners  | **      | **     **  | **      | **      |
|                         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > General Practitioners | **      | **     **  | **      | **      |
|                         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Internists            | **      | **     **  | **      | **      |
|                         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > OB/GYNs               | **      | **     **  | **      | **      |
|                         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Pediatricians         | **      | **     **  | **      | **      |
|                         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Other Specialty       | **      | **     **  | **      | **      |
| > Physicians (attach    |      ** |            |      ** |      ** |
| > list by type)         |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| > Physician             | **      | **     **  | **      | **      |
| > Assistants/Nurse      |      ** |            |      ** |      ** |
| > Practitioners         |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| > Certified Nurse       | **      | **     **  | **      | **      |
| > Midwives              |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Nurses (RNs, LVNs,    | **      | **     **  | **      | **      |
| > LPNs)                 |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Pharmacist, Pharmacy  | **      | **     **  | **      | **      |
| > Support, Technicians  |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Other Medical         | **      | **     **  | **      | **      |
| > Personnel (attach     |      ** |            |      ** |      ** |
| > list by type)         |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| > Laboratory Personnel  | **      | **     **  | **      | **      |
| > (Lab Technicians)     |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > X-ray Personnel       | **      | **     **  | **      | **      |
|                         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Clinical Support      | **      | **     **  | **      | **      |
| > Staff (Medical        |      ** |            |      ** |      ** |
| > Assistants, etc.)     |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| **DENTAL STAFF**        |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| > Dentists              | **      | **     **  | **      | **      |
|                         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Dental Hygienists     | **      | **     **  | **      | **      |
|                         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Dental Assistants,    | **      | **     **  | **      | **      |
| > Aides, Technicians    |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| **MENTAL HEALTH STAFF** |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| > Mental Health         | **      | **     **  | **      | **      |
| > Specialists (MH       |      ** |            |      ** |      ** |
| > Provider)             |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| > Alcohol and Substance | **      | **     **  | **      | **      |
| > Abuse Specialists     |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Psychiatrists         | **      | **     **  | **      | **      |
|                         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| **ENABLING STAFF**      |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| > Patient Education     | **      | **     **  | **      | **      |
| > Specialist (Health    |      ** |            |      ** |      ** |
| > Educator)             |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| > Case Managers         | **      | **     **  | **      | **      |
|                         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Outreach (Outreach    | **      | **     **  | **      | **      |
| > Staff)                |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| > Other Enabling        | **      | **     **  | **      | **      |
|                         |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+
| **OTHER PROFESSIONAL    | **      | **     **  | **      | **      |
| STAFF** (describe in    |      ** |            |      ** |      ** |
| narrative)              |         |            |         |         |
+-------------------------+---------+------------+---------+---------+
| **OTHER STAFF**         | **      | **     **  | **      | **      |
| (describe in narrative) |      ** |            |      ** |      ** |
+-------------------------+---------+------------+---------+---------+

![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}

##### FORM 3: INCOME ANALYSIS FORMAT {#form-3-income-analysis-format .unnumbered}

YEAR 1  YEAR 2  YEAR 3 

+----------------+-----+--------+-----+--------+-----+------+------+
| **PAYOR        | **  | **A    | *   | **A    | **  | **CO | **P  |
| CATEGORY**     | NUM | VERAGE | *TO | VERAGE | AMO | LLEC | ROJE |
|                | BER | CHARGE | TAL | ADJU   | UNT | TION | CTED |
|                | OF  | PER    | CHA | STMENT | BI  | RA   | INCO |
|                | VI  | V      | RGE | PER    | LLE | TE** | ME** |
|                | SIT | ISIT** | S** | V      | D** |      |      |
|                | S** |        |     | ISIT** |     | **(  | **(e |
|                |     |        | *   |        | *   | %)** | \*   |
|                |     |        | *(a |        | *\[ |      | f)** |
|                |     |        | \*  |        | c-( |      |      |
|                |     |        | b   |        | a\* |      |      |
|                |     |        | )** |        | d)\ |      |      |
|                |     |        |     |        | ]** |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
|                | *   | *      | *   | *      | *   | **(  | **(  |
|                | *(a | *(b)** | *(c | *(d)** | *(e | f)** | g)** |
|                | )** |        | )** |        | )** |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **FEE FOR      |     |        |     |        |     |      |      |
| SERVICE**      |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Medicaid:    |     |        |     |        |     |      |      |
| Medical**      |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Medicaid:    |     |        |     |        |     |      |      |
| EPSDT (if      |     |        |     |        |     |      |      |
| different from |     |        |     |        |     |      |      |
| Medical)**     |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Medicaid:    |     |        |     |        |     |      |      |
| Dental**       |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Medicaid:    |     |        |     |        |     |      |      |
| Behavioral**   |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Medicaid:    |     |        |     |        |     |      |      |
| Other Fee for  |     |        |     |        |     |      |      |
| Services**     |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Medicaid:    |     |        |     |        |     |      |      |
| Capitated**    |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Subtotal:    |     |        |     |        |     |      |      |
| Medicaid**     |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Medicare**   |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Medicare:    |     |        |     |        |     |      |      |
| Other Fee for  |     |        |     |        |     |      |      |
| Services**     |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Medicare:    |     |        |     |        |     |      |      |
| Capitated**    |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Subtotal:    |     |        |     |        |     |      |      |
| Medicare**     |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Private      |     |        |     |        |     |      |      |
| Insurance:     |     |        |     |        |     |      |      |
| Medical**      |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Private      |     |        |     |        |     |      |      |
| Insurance:     |     |        |     |        |     |      |      |
| Dental**       |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Private      |     |        |     |        |     |      |      |
| Insurance:     |     |        |     |        |     |      |      |
| Behavioral**   |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Self-Pay:    |     |        |     |        |     |      |      |
| 100% of charge |     |        |     |        |     |      |      |
| (no discount): |     |        |     |        |     |      |      |
| Medical**      |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Self-Pay:    |     |        |     |        |     |      |      |
| Sliding Fee    |     |        |     |        |     |      |      |
| Scale          |     |        |     |        |     |      |      |
| discounts:     |     |        |     |        |     |      |      |
| Medical**      |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Self-Pay: 0% |     |        |     |        |     |      |      |
| of charge,     |     |        |     |        |     |      |      |
| full discount: |     |        |     |        |     |      |      |
| Medical**      |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Self-Pay:    |     |        |     |        |     |      |      |
| 100% of charge |     |        |     |        |     |      |      |
| (no discount): |     |        |     |        |     |      |      |
| Dental**       |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Self-Pay:    |     |        |     |        |     |      |      |
| Sliding Fee    |     |        |     |        |     |      |      |
| Scale          |     |        |     |        |     |      |      |
| discounts:     |     |        |     |        |     |      |      |
| Dental**       |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Self-Pay: 0% |     |        |     |        |     |      |      |
| of charge,     |     |        |     |        |     |      |      |
| full discount: |     |        |     |        |     |      |      |
| Dental**       |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Self-Pay:    |     |        |     |        |     |      |      |
| 100% of charge |     |        |     |        |     |      |      |
| (no discount): |     |        |     |        |     |      |      |
| Behavioral**   |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Self-Pay:    |     |        |     |        |     |      |      |
| Sliding Fee    |     |        |     |        |     |      |      |
| Scale          |     |        |     |        |     |      |      |
| discounts:     |     |        |     |        |     |      |      |
| Behavioral**   |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Self-Pay: 0% |     |        |     |        |     |      |      |
| of charge,     |     |        |     |        |     |      |      |
| full discount: |     |        |     |        |     |      |      |
| Behavioral**   |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Other:       |     |        |     |        |     |      |      |
| Capitation**   |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Other:       |     |        |     |        |     |      |      |
| Contracts**    |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **SUB-TOTAL**  |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **OTHER        |     |        |     |        |     |      |      |
| INCOME**       |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Contributio  |     |        |     |        |     |      |      |
| ns/Donations** |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Fund         |     |        |     |        |     |      |      |
| Raising**      |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **330 BPHC     |     |        |     |        |     |      |      |
| Grant**        |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Other        |     |        |     |        |     |      |      |
| Federal        |     |        |     |        |     |      |      |
| Grants**       |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **State        |     |        |     |        |     |      |      |
| Grants**       |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Local        |     |        |     |        |     |      |      |
| Support**      |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Foundation   |     |        |     |        |     |      |      |
| Grants**       |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **Other**      |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+
| **GRAND        |     |        |     |        |     |      |      |
| TOTAL**        |     |        |     |        |     |      |      |
+----------------+-----+--------+-----+--------+-----+------+------+

![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}

##### FORM 4: COMMUNITY CHARACTERISTICS {#form-4-community-characteristics .unnumbered}

**Instructions to Applicants**: Community-wide and target population
data should reflect all counties, cities, etc., in the applicant's
proposed scope of the project. Community-wide data should include the
total number of persons and the percent of the total population in the
service area for each characteristic. Target population data is a subset
of the community-wide data. Target population includes the number of
persons and the percent of the total population the health center
**[targets]{.underline}** for each characteristic. Estimates are
acceptable. *Please do not utilize user/patient data reported in the
Uniform Data System to report target population data.*

+------------+-----------------------+-------+-------+--------+------+
|            | **CHARACTERISTIC**    | *     |       | **     |      |
|            |                       | *COMM |       | TARGET |      |
|            |                       | UNITY |       | POPU   |      |
|            |                       | WIDE  |       | LATION |      |
|            |                       | D     |       | DATA** |      |
|            |                       | ATA** |       |        |      |
|            |                       |       |       | **\#   |      |
|            |                       | **\#  |       | %**    |      |
|            |                       | %**   |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
| RACE       | White (non-Hispanic)  |       |       |        |      |
| /ETHNICITY |                       |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Black or              |       |       |        |      |
|            | African-American      |       |       |        |      |
|            | (non-Hispanic)        |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Hispanic              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | American Indian or    |       |       |        |      |
|            | Alaskan Native        |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Asian                 |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Native Hawaiian or    |       |       |        |      |
|            | Other Pacific         |       |       |        |      |
|            | Islander              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Other (Please         |       |       |        |      |
|            | specify)              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Total Population      |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
| INCOME AS  | Below 100%            |       |       |        |      |
| A PERCENT  |                       |       |       |        |      |
| OF POVERTY |                       |       |       |        |      |
| LEVEL      |                       |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | 100-199 percent       |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | 200 percent and above |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Unknown               |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
| PRIMARY    | Medicaid/Capitated    |       |       |        |      |
| THIRD      |                       |       |       |        |      |
| PARTY      |                       |       |       |        |      |
| PAYMENT    |                       |       |       |        |      |
| SOURCE     |                       |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Medicaid/Not          |       |       |        |      |
|            | Capitated             |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Medicare              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Other Public          |       |       |        |      |
|            | Insurance             |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Private Insurance,    |       |       |        |      |
|            | including capitation  |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | None/Uninsured        |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
| SPECIAL    | Migrant/ Seasonal     |       |       |        |      |
| P          | Farmworkers and       |       |       |        |      |
| OPULATIONS | Families              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Homeless People       |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | HIVAIDS-Infected      |       |       |        |      |
|            | Persons               |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Persons with Mental   |       |       |        |      |
|            | Health/Substance      |       |       |        |      |
|            | Abuse                 |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Residents of Public   |       |       |        |      |
|            | Housing               |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | School Age Children   |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Infants Birth to 2    |       |       |        |      |
|            | years of Age          |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Women Age 25 - 44     |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Persons Age 65 and    |       |       |        |      |
|            | Older                 |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+
|            | Other: (Please        |       |       |        |      |
|            | specify)              |       |       |        |      |
+------------+-----------------------+-------+-------+--------+------+

![](media/image1.wmf){width="1.4618055555555556in" height="0.23125in"}

##### FORM 5 -- Part A: SERVICES PROVIDED {#form-5-part-a-services-provided .unnumbered}

  ----------- ---------------------- ---------- ----------- ----------- ---------- ---------------- ---------- ----------- -----------
  SERVICE                            PROVIDED   BY          BY          SERVICE                     PROVIDED   BY          BY
  TYPE                               BY GRANTEE REFERRAL/   REFERRAL/   TYPE                        BY GRANTEE REFERRAL/   REFERRAL/
                                                GRANTEE     GRANTEE                                            GRANTEE     GRANTEE
                                                PAYS        DOESN'T PAY                                        PAYS        DOESN'T PAY

  PRIMARY     General Primary                                           OTHER      Environmental                           
  MEDICAL     Medical Care                                              SERVICES   Health                                  
  CARE                                                                                                                     
  SERVICES                                                                                                                 

              Diagnostic Laboratory                                                Hearing                                 
                                                                                   Screening                               

              Diagnostic X-Ray                                                     Nutrition (not                          
                                                                                   WIC)                                    

              Diagnostic                                                           Occ./Voc.                               
              Tests/Screens                                                        Therapy                                 

              Urgent Medical Care                                                  Physical Therapy                        

              24-Hour Coverage                                                     Pharmacy                                

              Family Planning                                                      Podiatry                                

              HIV Testing                                                          Vision Screening                        

              Immunizations                                                        WIC                                     

              Following Hospitalized                                    ENABLING   Case Management                         
              Patients                                                  SERVICES                                           

  OB/GYN CARE Gynecological Care                                                   Child Care                              

              Obstetrical Care                                                     Discharge                               
                                                                                   Planning                                

  SPECIALTY   TB Therapy                                                           Eligibility                             
  SERVICES                                                                         Assistance                              

              Other                                                                Emp./Ed.                                
                                                                                   Counseling                              

              Other                                                                Food Bank/Meals                         

  DENTAL      Preventive                                                           Health Education                        
  SERVICES                                                                                                                 

              Restorative                                                          Homemaker/Aide                          

              Emergency                                                            Housing                                 
                                                                                   Assistance                              

              Other                                                                Translation                             

  MENTAL      Treatment/Counseling                                                 Nursing Home and                        
  HEALTH                                                                           Other Placement                         
  SERVICES                                                                                                                 

              Developmental                                                        Outreach                                
              Screening                                                                                                    

              24-Hour Crisis                                                       Transportation                          

              Other Mental Health                                                  Other:                                  

              Substance Abuse                                                      Other:                                  

              Other Substance Abuse                                                Other:                                  
  ----------- ---------------------- ---------- ----------- ----------- ---------- ---------------- ---------- ----------- -----------

![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}

##### FORM 5 -- Part B: SERVICE SITES \*\* {#form-5-part-b-service-sites .unnumbered}

+----------------------------------+-----------------------------------+
| **SITE #1**                      | SITE #2                           |
+----------------------------------+-----------------------------------+
| Year-Round Seasonal Full-Time    | Year-Round Seasonal Full-Time     |
| Part-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    | City       State       Zip (9     |
| digit required)                  | digit required)                   |
|                                  |                                   |
| Phone No.       Fax No.          | Phone No.       Fax No.           |
|                                  |                                   |
| Service Area:                    | Service Area:                     |
|                                  |                                   |
| Relevant Congressional District: | Relevant Congressional District:  |
|                                  |                                   |
|                                  |                                   |
| Relevant County Name:            | Relevant County Name:             |
|                                  |                                   |
| Relevant Census Tracts:          | Relevant Census Tracts:           |
|                                  |                                   |
| Urban/Rural/Sparsely Populated:  | Urban/Rural/Sparsely Populated:   |
|                                  |                                   |
|                                  |                                   |
| Other HRSA Funding Source(s):    | Other HRSA Funding Source(s):     |
|                                  |                                   |
+----------------------------------+-----------------------------------+
| SITE #3                          | SITE #4                           |
+----------------------------------+-----------------------------------+
| Year-Round Seasonal Full-Time    | Year-Round Seasonal Full-Time     |
| Part-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    | City       State       Zip (9     |
| digit required)                  | digit required)                   |
|                                  |                                   |
| Phone No.       Fax No.          | Phone No.       Fax No.           |
|                                  |                                   |
| Service Area:                    | Service Area:                     |
|                                  |                                   |
| Relevant Congressional District: | Relevant Congressional District:  |
|                                  |                                   |
|                                  |                                   |
| Relevant County Name:            | Relevant County Name:             |
|                                  |                                   |
| Relevant Census Tracts:          | Relevant Census Tracts:           |
|                                  |                                   |
| Urban/Rural/Sparsely Populated:  | Urban/Rural/Sparsely Populated:   |
|                                  |                                   |
|                                  |                                   |
| Other HRSA Funding Source(s):    | Other HRSA Funding Source(s):     |
|                                  |                                   |
+----------------------------------+-----------------------------------+
| SITE #5                          | SITE #6                           |
+----------------------------------+-----------------------------------+
| Year-Round Seasonal Full-Time    | Year-Round Seasonal Full-Time     |
| Part-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    | City       State       Zip (9     |
| digit required)                  | digit required)                   |
|                                  |                                   |
| Phone No.       Fax No.          | Phone No.       Fax No.           |
|                                  |                                   |
| Service Area:                    | Service Area:                     |
|                                  |                                   |
| Relevant Congressional District: | Relevant Congressional District:  |
|                                  |                                   |
|                                  |                                   |
| Relevant County Name:            | Relevant County Name:             |
|                                  |                                   |
| Relevant Census Tracts:          | Relevant Census Tracts:           |
|                                  |                                   |
| Urban/Rural/Sparsely Populated:  | Urban/Rural/Sparsely Populated:   |
|                                  |                                   |
|                                  |                                   |
| Other HRSA Funding Source(s):    | Other HRSA Funding Source(s):     |
|                                  |                                   |
+----------------------------------+-----------------------------------+

\*\* New start applicants should list all sites to be included in the
scope of project

\*\* Satellite applicants should list all sites in the current scope of
project and identify the proposed satellite site(s)

NOTE: ADD ADDITIONAL PAGES, IF
NEEDED.![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}

**INSTRUCTIONS FOR FORM 5 -- PART B: SERVICE SITES**

The name and address of each service site that meets the definition of a
site (see NAP definitions in this guidance) must be listed in Form 5 --
Part B: Service Sites.

*Special Instructions for Recording Mobile Van Sites*

A mobile van that provides primary care services at multiple locations
is considered a service site. For each mobile van, health centers should
identify the site as a mobile van and list the address for the grantee
of record 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 Health Centers That Contract With Nursing
Homes To Provide Primary Care To All Nursing Home Patients*

In some instances, health centers may enter into a contract with a
nursing home to provide primary care services to nursing home residents
on a regularly scheduled basis. The name and address of the nursing home
should be listed on Form 5 -- Part B: Service Sites if [all]{.underline}
of the following conditions are met. The health center:

-   Has control and authority over provision of care by enrolling all
    nursing home residents as health center patients;

-   Bills for the services provided; and

-   Maintains medical records on all patients.

If the activities at the nursing home do not meet all of these
conditions, then the nursing home is not a site and should not be listed
on Form 5 -- Part B. For another type of activity that health centers
may conduct at nursing homes, please see the instructions for Form 5 --
Part C: Other Activities/Locations. [As a reminder, contracts must be in
compliance with section 330 of the Public Health Service
Act.]{.underline} In addition, [the health center's governing board must
approve all contracts and retain authority over the health center's
policy and procedures at the nursing home site, such as budget, hours,
services provided.]{.underline}

*Special Instructions for Recording Intermittent Service Sites*

HRSA recognizes the tendency for some types of service locations to
change with some frequency due to seasonality or population movement.
Thus service locations that do not meet the definition of a site because
services are not provided at the location on a regularly scheduled
basis, or are provided only on an intermittent/temporary/seasonal basis,
should be listed on Form 5 -- Part C (see instructions for Form 5 --
Part C).

Examples of these types of service locations might include homeless
shelters or migrant camps. In these cases, the entry on Form 5 -- Part C
should identify the location category, e.g., "Homeless Shelters,"
"Migrant Camps," and a brief description of the services/activities
provided. The addresses of all of the locations in the category do not
need to be listed. Please note that some homeless shelters and migrant
camps will meet the definition of a service site, and therefore, those
service sites should be listed, with addresses, on Form 5 -- Part B.

##### FORM 5 - PART C: OTHER ACTIVITIES/LOCATIONS {#form-5---part-c-other-activitieslocations .unnumbered}

Please see definition of service site in Appendix F, to determine those
activities or locations that should be listed on this Form. Service
sites should be listed on Form 5-Part B.

+----------------------------------+-----------------------------------+
| **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:            |
|                                  |                                   |
|                                  |                                   |
+----------------------------------+-----------------------------------+

![](media/image1.wmf){width="1.4618055555555556in" height="0.23125in"}

**INSTRUCTIONS FOR FORM 5 -- PART C: OTHER ACTIVITIES/LOCATIONS**

Health centers often 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
also should 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 health center providers follow the
    health center's patients (rounding/making rounds). Applicants should
    list the category, "hospital."

-   If a provider is required as part of his/her privileges to see
    non-health center patients at a hospital (on call), this activity
    may be covered by Federal Tort Claims Act, but it would not be a
    health center's site of service. Applicants should list the
    category, "hospital."

-   Nursing homes, in instances where health center providers follow the
    health center's patients. Applicants should list, "nursing home."

-   Rehabilitation facilities, in instances where health center
    providers follow the health center's patients. Applicants should
    list, "rehabilitation facility."

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

-   Hospice facilities, in instances where health center providers
    follow the health center's patients. Applicants should list,
    "hospice facility."

-   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."

##### FORM 6 -- Part A: CURRENT BOARD MEMBER CHARACTERISTICS {#form-6-part-a-current-board-member-characteristics .unnumbered}

+--------------------+---------+-----------+--------+-----+-----------+
| **BOARD MEMBER     | **BOARD | **AREA OF | **IN   | **L | **YEARS   |
| NAME**             | OFFICE  | EX        | DICATE | IVE | OF        |
|                    | HELD**  | PERTISE** | IF     | (L) | C         |
|                    |         |           | USER   | OR  | ONTINUOUS |
|                    |         |           | OF     | W   | BOARD     |
|                    |         |           | 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) HCH, MHC and/or PHPC applicants requesting a waiver of the
> governance requirements must complete Form 6, Part B and must 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.![](media/image1.wmf){width="1.4618055555555556in"
> height="0.23125in"}![](media/image1.wmf){width="1.4618055555555556in"
> height="0.23125in"}

#####  {#section-11 .unnumbered}

##### FORM 6 -- Part B: REQUEST FOR WAIVER OF GOVERNANCE REQUIREMENTS {#form-6-part-b-request-for-waiver-of-governance-requirements .unnumbered}

For health centers that are seeking support for MHC, HCH, or PHPC
**[only]{.underline}** if necessary.

REQUESTS FOR WAIVERS WILL **NOT** BE GRANTED IF APPLICANT ALSO RECIEVES
OR IS REQUESTING CHC FUNDING.

Name of Organization: [     ]{.underline}

Name of Sponsoring Organization (if different): [     ]{.underline}

**[If existing grantee with Waiver Approval:]{.underline}**

1\. Date of Original Governance Waiver Request:       (M/D/YR)

2\. Date of Waiver Approval by BPHC Director:       (M/D/YR)

3\. Date of Most Recent approval of

Continuation of Waiver Request (if different):       (M/D/YR)

4\. Nature of Requirements Currently Approved to be Waived:

: 51 Percent User Majority : Monthly Meetings

5\. Are you requesting the waiver(s) be continued?

> Yes (Complete questions 1. and 2. below)
>
> No (Governing Board is in Full Compliance)

If Yes, is your waiver request based on arrangements that are different
from your original request? Yes No

Progress made toward meeting full compliance?

[          ]{.underline}

**[Nature of Items for New Waiver Request:]{.underline}**

: 51 Percent User Majority : Monthly Meetings

**[All organizations Requesting Waiver:]{.underline}**

Describe below the arrangements that are in place to assure appropriate
user input and involvement is achieved, as well as plans for achieving
compliance. Use additional space as needed. (See PIN 98-12 for
additional guidance).

[          ]{.underline}

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[     ]{.underline}

Signature of Governing Board Chairperson Date

![](media/image1.wmf){width="1.4618055555555556in" height="0.23125in"}

#####  FORM 7: COMPLIANCE CHECKLIST -- Page 1 of 2 {#form-7-compliance-checklist-page-1-of-2 .unnumbered}

#####  {#section-12 .unnumbered}

#####  {#section-13 .unnumbered}

+---+-----------------------------------------------------------+---+---+
|   |                                                           | * | * |
|   |                                                           | * | * |
|   |                                                           | Y | N |
|   |                                                           | E | O |
|   |                                                           | S | * |
|   |                                                           | * | * |
|   |                                                           | * |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Is the applicant organization a non-profit or public      |   |   |
| . | entity?                                                   |   |   |
|   |                                                           |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization demonstrate the need for  |   |   |
| . | primary health care services in the community(ies) that   |   |   |
|   | make up its service area based on geographic,             |   |   |
|   | demographic, and economic factors?                        |   |   |
+---+-----------------------------------------------------------+---+---+
| 3 | Does the applicant organization serve, in whole or in     |   |   |
| . | part, a designated MUA or MUP? *(Requested, not required  |   |   |
|   | for HCH, PHPC or MHC applicants)*                         |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 4 | Does the applicant organization have a system of care     |   |   |
| . | that contributes to the availability, accessibility,      |   |   |
|   | quality, comprehensiveness and coordination of health     |   |   |
|   | services in the service area?                             |   |   |
+---+-----------------------------------------------------------+---+---+
| 5 | Does the applicant organization provide ready access for  |   |   |
| . | all persons to all of the required primary, preventive    |   |   |
|   | and supplemental health services, including oral health   |   |   |
|   | care, mental health care and substance abuse services     |   |   |
|   | without regard to ability to pay either directly on-site  |   |   |
|   | or through established arrangements?                      |   |   |
+---+-----------------------------------------------------------+---+---+
| 6 | Does the applicant organization provide all additional    |   |   |
| . | health services as appropriate and necessary?             |   |   |
|   |                                                           |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 7 | Does the applicant organization have patient case         |   |   |
| . | management services (including counseling, referral and   |   |   |
|   | follow-up 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,  |   |   |
|   | educational or other related services?                    |   |   |
+---+-----------------------------------------------------------+---+---+
| 8 | Does the applicant organization collaborate appropriately |   |   |
| . | with other health and social service providers in their   |   |   |
|   | area?                                                     |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 9 | Are all contracted services (including management         |   |   |
| . | agreements, administrative services contracts, etc.)      |   |   |
|   | under the governance, administration, quality assurance   |   |   |
|   | and clinical management policies of the applicant         |   |   |
|   | organization?                                             |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Does the applicant organization arrange referrals to      |   |   |
| 0 | providers as may be appropriate to assure ready access    |   |   |
| . | for all persons to all of the required primary,           |   |   |
|   | preventive and supplemental health services without       |   |   |
|   | regard to ability to pay?                                 |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Are all services available to all persons in the service  |   |   |
| 1 | area or target population regardless of age, gender, or   |   |   |
| . | the patient's ability to pay?                             |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Does the applicant organization maintain a core staff of  |   |   |
| 2 | primary care providers appropriate for the population     |   |   |
| . | served?                                                   |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Are the primary care providers working at the health      |   |   |
| 3 | center licensed to practice in the State where the center |   |   |
| . | is located?                                               |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Have all providers been properly credentialed and         |   |   |
| 4 | privileged according to PINs 99-08 and 2001-11?           |   |   |
| . |                                                           |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Do the applicant organization's physicians have admitting |   |   |
| 5 | privileges at their referral hospital(s), or other such   |   |   |
| . | arrangement to ensure continuity of care?                 |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Does the applicant organization use a charge schedule     |   |   |
| 6 | with a corresponding discount schedule based on income    |   |   |
| . | for persons between 100 percent and 200 percent of the    |   |   |
|   | Federal poverty level?                                    |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Is/will the new access point be open to provide services  |   |   |
| 7 | at the times that meet the needs of the majority of       |   |   |
| . | potential users?                                          |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+

![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}

##### FORM 7: COMPLIANCE CHECKLIST -- Page 2 of 2 {#form-7-compliance-checklist-page-2-of-2 .unnumbered}

+---+-----------------------------------------------------------+---+---+
|   |                                                           | * | * |
|   |                                                           | * | * |
|   |                                                           | Y | N |
|   |                                                           | E | O |
|   |                                                           | S | * |
|   |                                                           | * | * |
|   |                                                           | * |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Does the applicant organization provide professional      |   |   |
| 8 | coverage during hours when the center is closed?          |   |   |
| . |                                                           |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 1 | Does the applicant organization have clear lines of       |   |   |
| 9 | authority from the Board to a chief executive (President, |   |   |
| . | Chief Executive Officer or Executive Director) who        |   |   |
|   | delegates, as appropriate, to other management and        |   |   |
|   | professional staff?                                       |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization have systems which        |   |   |
| 0 | accurately collect and organize data 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?                                               |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization have accounting and       |   |   |
| 1 | internal control systems 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?                                                   |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization maximize revenue from     |   |   |
| 2 | third party payers and from patients to the extent they   |   |   |
| . | are able to pay?                                          |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization have written billing,     |   |   |
| 3 | credit and collection policies and procedures?            |   |   |
| . |                                                           |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization assure that an annual     |   |   |
| 4 | independent financial audit is performed in accordance    |   |   |
| . | with Federal audit requirements?                          |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the applicant organization have a governing board    |   |   |
| 5 | that is composed of individuals, a majority of whom are   |   |   |
| . | being served by the organization and, who as a group,     |   |   |
|   | represent the individuals being serviced by the center?   |   |   |
|   | (May be waived for MHC, HCH or PHPC applicants. See Form  |   |   |
|   | 6, Part B)                                                |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Does the governing board have at least 9 but no more than |   |   |
| 6 | 25 members? (*Requested, not required for HCH or PHPC     |   |   |
| . | applicants)*                                              |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Do the corporate bylaws require the governing board to    |   |   |
| 7 | meet at least one per month? (May be waived for HCH, MHC  |   |   |
| . | or PHPC applicants. See Form 6 -- Part B)                 |   |   |
|   |                                                           |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Do the applicant organization's corporate bylaws          |   |   |
| 8 | demonstrate that the governing board has the required     |   |   |
| . | authority and responsibility to oversee the operation of  |   |   |
|   | the center?                                               |   |   |
+---+-----------------------------------------------------------+---+---+
| 2 | Do the corporate bylaws include provisions that prohibit  |   |   |
| 9 | conflict of interest or the appearance of conflict of     |   |   |
| . | interest by board members, employees, consultants and     |   |   |
|   | those who provide services or furnish goods to the        |   |   |
|   | center?                                                   |   |   |
+---+-----------------------------------------------------------+---+---+

**I certify that the information contained herein is accurate to the
best of my knowledge.**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[     ]{.underline}

Signature of Governing Board Chairperson Date Date

[          ]{.underline}

Printed Name

![](media/image1.wmf){width="1.4618055555555556in" height="0.23125in"}

##### FORM 8- Part A: HEALTH CENTER AFFILIATION CERTIFICATION  {#form-8--part-a-health-center-affiliation-certification .unnumbered}

**(MUST BE COMPLETED BY ALL CHC or MHC APPLICANTS)**

**Organization: [     ]{.underline} UDS \#** [     ]{.underline}

*(where applicable)*

**1. Does your organization have, or propose to establish as part of the
new access point application, 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.
Copies of all applicable documents must be included with the
application.)**

YES *(Please check all that apply and complete and submit FORM 8 -- Part
B)*

NO *(Certify below and submit only this page with application)*

> a) Contract for a substantial portion of the approved scope of project
>
> b) Memorandum of Understanding (MOU)/Agreement (MOA) for a substantial
> portion of the approved scope of 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:      

     

Name of Affiliating Organization:      

Address:      

     

Name of Affiliating Organization:      

Address:      

     

**I certify that the information contained herein is accurate to the
best of my knowledge.**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[     ]{.underline}

Signature of Governing Board Chairperson Date

[          ]{.underline}![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}

Printed Name

##### FORM 8 -- Part B: HEALTH CENTER AFFILIATION CHECKLIST {#form-8-part-b-health-center-affiliation-checklist .unnumbered}

+----------------------------------------------------+------+----+----+
| **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 2 or 3, the CEO of the center  |      |    |    |
| > retains the authority to select and dismiss      |      |    |    |
| > staff assigned to the center. Please cite        |      |    |    |
| > reference document and page #.       (*If NO to  |      |    |    |
| > question 1 or 2, the applicant must submit a     |      |    |    |
| > request for a good cause exception. Please see   |      |    |    |
| > PIN 98-24.)*                                     |      |    |    |
+----------------------------------------------------+------+----+----+
| **GOVERNANCE:**                                    |      | *  | ** |
|                                                    |      | *Y | NO |
|                                                    |      | ES | ** |
|                                                    |      | ** |    |
+----------------------------------------------------+------+----+----+
| 3\) The Governing Board structure is in compliance |      |    |    |
| with all section 330 requirements.                 |      |    |    |
+----------------------------------------------------+------+----+----+
| 4\) The Governing Board retains its full           |      |    |    |
| authorities, responsibilities and functions as     |      |    |    |
| prescribed in legislation/regulations/HRSA         |      |    |    |
| guidelines in regard to the following as           |      |    |    |
| identified below.                                  |      |    |    |
+----------------------------------------------------+------+----+----+
| 5\) The arrangements presented in the affiliation  |      |    |    |
| agreements, as defined in Question 1 of FORM 8 --  |      |    |    |
| Part A, do not compromise the Board authorities or |      |    |    |
| limit its legislative and regulatory mandated      |      |    |    |
| functions and responsibilities. *(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    |    | Pa |
|                                                    | efer |    | ge |
|                                                    | 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.                                    |      |    |    |
+----------------------------------------------------+------+----+----+
| **INCLUDE LIST AND COPIES OF ALL RELEVANT AND      |      |    |    |
| CITED DOCUMENTS**                                  |      |    |    |
+----------------------------------------------------+------+----+----+

**I certify that the information contained herein is accurate to the
best of my knowledge.**

Printed Name Signature of Governing Board Chairperson
Date![](media/image1.wmf){width="1.4618055555555556in"
height="0.23125in"}

##### FORM 9 -- Part A: NEED FOR ASSISTANCE WORKSHEET CRITERIA {#form-9-part-a-need-for-assistance-worksheet-criteria .unnumbered}

*As part of the application, applicants MUST COMPLETE AND SUBMIT the
Need for Assistance Worksheet found in FORM 9 -- PART B. **Applicants
that** score 70 or higher **on the need for assistance component of the
application** will have the merits of the application evaluated **by
reviewers using published review criteria with points assigned up to a
maximum of 100 points.***

The scoring of Need for Assistance will be based on data about both the
proposed service area and target population. **New start applicants**
are expected to provide data for the proposed scope of project.
**Satellite applicants** are expected to provide data for the **proposed
new service delivery site ONLY.** If more than one site or target
population is included in the proposal, the Need for Assistance
worksheet is expected to provide data on the combined data for all
target populations and sites.(i.e., only one comprehensive Need for
Assistance Worksheet will be accepted). If target population data are
not available for any of the following rating criteria, the applicant
may provide service area data only. Applicants are expected to provide
the most recently available data.

The following guidelines are in place for completing the Need for
Assistance Worksheet. If the responses to the Need for Assistance
Worksheet are not presented appropriately, as described below, the
applicant may receive the minimum points allowed for the applicable
question.

1.  All responses must be given in the format requested (i.e., if a
    percentage is requested, the response must be a percentage; if a
    rate is requested, the response must be a rate).

2.  Documentation of the source of the data is required.

3.  Data cited must be the most recent data available.

4.  Data must be from a reliable and independent source including:
    Census data; Service area data; Local or State-level data; and/or
    National data, where no other data is available. NOTE: Applicants
    should use the most geographically focused data available.
    Applicants may not use data generated by their own internal data
    systems on the populations currently being served by the applicant
    to complete the Need for Assistance Worksheet.

5.  Each response must clearly address the target population(s) to be
    served. If an applicant proposes to serve multiple sites or service
    areas, the Need for Assistance Worksheet should include responses
    that represent the total targeted populations/areas. No more than
    one response should be submitted for each question.

6.  All responses must be finite numbers (i.e., 212) and cannot be
    presented as ranges (i.e., 31-35).

7.  In completing the Health Disparities section, a response must be
    presented for the target population as well as for the benchmark
    area. A different response, such as County, State, National or other
    established reporting area, must also be provided be used as a point
    of comparison for the target population. As with item #4, applicants
    should use the most geographically focused data available for both
    the target population and the benchmark area.

8.  Only one response may be provided under the Health Disparity Factor
    "2bb. Other".

Eligible applicants will be evaluated in accordance with the following
criteria (total 100 points):

1.  BARRIERS AND ACCESS TO CARE: each applicant must respond to **FIVE**
    of the following: (maximum 70 points)

\(a\) **Geographic barriers** based on average travel time/distance by
the means most commonly used by the target population (e.g., car, public
transportation, walking, etc.) from home/shelter/ camp to the nearest
source of primary care that is accessible to the target population
(e.g., a physician willing to accept new Medicaid patients and/or has a
published sliding fee schedule for people below 200 percent of poverty).

0 -- 20 minutes 0 points

21 -- 29 minutes 6 points

30 -- 44 minutes 8 points

45 -- 59 minutes 10 points

60 -- 74 minutes 12 points

75 + minutes 14 points

**or**

0 -- 10 miles 0 points

11 -- 19 miles 6 points

20 -- 29 miles 8 points

30 -- 49 miles 10 points

50 -- 59 miles 12 points

60 + miles 14 points

\(b\) **Length of waiting time** for public housing and Section 8
certificates in the proposed service area:

> Less than 90 days 0 points
>
> 3 -- 5 months 6 points

6 -- 12 months 8 points

> 13 -- 18 months 10 points
>
> 19 -- 24 months 12 points
>
> Greater than 25 months 14 points

\(c\) Percentage of population 5 years or older who speak a **language
other than English** at home:

\<1 % 0 points

1 -- 2 % 6 points

3 -- 4 % 8 points

5 -- 7 % 10 points

8 -- 12 % 12 Points

13 + % 14 points

\(d\) **Shortage of primary care physicians** necessary to meet the
needs of the target population = Designation of the service area as a
Federal Health Professional Shortage Area (HPSA):

NO 0 points

YES 14 points

\(e\) **Percentage of Individuals Below 200 percent** of the Federal
Poverty Index in the Target Population

> 0 - 9% 0 points
>
> 10 - 19% 6 points
>
> 20 - 29% 8 points
>
> 30 - 39% 10 points
>
> 40 - 49% 12 points
>
> 50+ % 14 points

\(f\) **Life Expectancy Rate** (based on life expectancy at birth in
years):

> 82+ years 0 points
>
> 77 -- 81 years 8 points
>
> 73 -- 76 years 10 points
>
> 68 -- 72 years 12 points
>
> 0 -- 67 years 14 points

\(g\) **Percentage of Uninsured Individuals** in the Target Population
\[If information is unavailable, use number of individuals below 200
percent of poverty minus the number of Medicaid beneficiaries\]

> 0 - 9% 0 points

10 - 14% 8 points

> 15 - 24% 10 points
>
> 25 - 34% 12 points
>
> 35+ % 14 points

\(h\) **Unemployment rate** in the target population

> 0 -- 1 % 0 points
>
> 2 -- 3.5 % 6 points
>
> 3.6 -- 5.0 % 8 points
>
> 5.1 -- 6.5 % 10 points
>
> 6.6 -- 8.0 % 12 points
>
> 8.1+ % 14 points

2\. HEALTH DISPARITY FACTORS: Each applicant must respond to **ten**
(**10**) of the following items. Responses must be based on the
rate/percentage/etc., in the proposed TARGET POPULATION. If information
is not available for the target population, service area data may be
substituted. If the application proposes to serve a special population
group, responses in this section should demonstrate the unique Health
Disparities of the special population. (3 points each - maximum 30
points)

> 2a. Cancer rate (age adjusted death rate for all cancers per 100,000
> people)
>
> 2b. Low birthweight rate (per 1,000 live births)
>
> 2c. Infant mortality rate (per 1,000 live births)
>
> 2d. Rate of exposure (i.e., hypothermia, heat stroke, etc.)
>
> 2e. Asthma rate
>
> 2f. Diabetes rate
>
> 2g. Nutrition rate (e.g., hunger, malnutrition, etc.)
>
> 2h. Coronary heart disease rate (age adjusted death rate for all
> cancers per 100,000 people)
>
> 2i. Rate of occupational (e.g., pesticide) and environmental hazard
> exposures
>
> 2j. Skin disorders rate (e.g., acne, eczema, ring worm, etc.)
>
> 2k. Dental disease rate (e.g., caries, lack of teeth, periodontal
> disease)
>
> 2l. Teen pregnancy rate
>
> 2m. Late entry into prenatal care
>
> 2n. Obesity rate
>
> 2o. Depression rate
>
> 2p. Suicide rate
>
> 2q. Hypertension rate
>
> 2r. HIV/AIDS/STDs rate
>
> 2s. Unintentional injury rate
>
> 2t. Percent of elderly
>
> 2u. Substance abuse rate
>
> 2v. ADD/ADHD rate
>
> 2w. Rate of respiratory infection
>
> 2x. Immunization rate
>
> 2y. Rate of school absenteeism
>
> 2z. Percent of minority populations
>
> 2aa. Rate of serious mental illness (e.g., schizophrenia, bi-polar,
> etc.)
>
> 2bb. Other (must be health related): *ONE RESPONSE ONLY*

##### FORM 9 -- Part B: NEED FOR ASSISTANCE WORKSHEET -- FY 2007 {#form-9-part-b-need-for-assistance-worksheet-fy-2007 .unnumbered}

***MUST BE COMPLETED AND INCLUDED WITH THE GRANT APPLICATION***

All responses in this section must be given in the format requested
(i.e., if a percentage is requested, the response must be a percentage;
if a rate is requested, the response must be a rate). ***If the response
is not provided in the requested format, the applicant will receive the
minimum points allowed for that question.***

Documentation of the source of the data is required. ***If there is no
source documented, the applicant will only receive the minimum points
allowed for that question.***

**Applications that score 70 or higher on the need for assistance
component of the application will have the merits of the application
evaluated by an Independent Review Committee.**

See Form 9 -- Part A, page
[116](#form-9-part-a-need-for-assistance-worksheet-criteria), for
scoring of the Need for Assistance Worksheet**.**

+-----+--------------------+-------+---+---+---+----------+-----------+
| **R |                    |       |   |   |   |          |           |
| esp |                    |       |   |   |   |          |           |
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| orm |                    |       |   |   |   |          |           |
| 9   |                    |       |   |   |   |          |           |
| --  |                    |       |   |   |   |          |           |
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| S   |                    |       |   |   |   |          |           |
| ect |                    |       |   |   |   |          |           |
| ion |                    |       |   |   |   |          |           |
| 1   |                    |       |   |   |   |          |           |
| .** |                    |       |   |   |   |          |           |
| Ple |                    |       |   |   |   |          |           |
| ase |                    |       |   |   |   |          |           |
| wr  |                    |       |   |   |   |          |           |
| ite |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| Qu  |                    |       |   |   |   |          |           |
| est |                    |       |   |   |   |          |           |
| ion |                    |       |   |   |   |          |           |
| \#  |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| fi  |                    |       |   |   |   |          |           |
| rst |                    |       |   |   |   |          |           |
| c   |                    |       |   |   |   |          |           |
| olu |                    |       |   |   |   |          |           |
| mn, |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| qu  |                    |       |   |   |   |          |           |
| est |                    |       |   |   |   |          |           |
| ion |                    |       |   |   |   |          |           |
| s   |                    |       |   |   |   |          |           |
| ubj |                    |       |   |   |   |          |           |
| ect |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| for |                    |       |   |   |   |          |           |
| mat |                    |       |   |   |   |          |           |
| ion |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| sec |                    |       |   |   |   |          |           |
| ond |                    |       |   |   |   |          |           |
| c   |                    |       |   |   |   |          |           |
| olu |                    |       |   |   |   |          |           |
| mn, |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| app |                    |       |   |   |   |          |           |
| lic |                    |       |   |   |   |          |           |
| ant |                    |       |   |   |   |          |           |
| re  |                    |       |   |   |   |          |           |
| spo |                    |       |   |   |   |          |           |
| nse |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| th  |                    |       |   |   |   |          |           |
| ird |                    |       |   |   |   |          |           |
| col |                    |       |   |   |   |          |           |
| umn |                    |       |   |   |   |          |           |
| and |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| sou |                    |       |   |   |   |          |           |
| rce |                    |       |   |   |   |          |           |
| for |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| re  |                    |       |   |   |   |          |           |
| spo |                    |       |   |   |   |          |           |
| nse |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| fou |                    |       |   |   |   |          |           |
| rth |                    |       |   |   |   |          |           |
| c   |                    |       |   |   |   |          |           |
| olu |                    |       |   |   |   |          |           |
| mn. |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| Que | Question Subject   |       |   | R |   | >        |           |
| st. | information (e.g., |       |   | e |   | Identify |           |
| \#  | "Geographic        |       |   | s |   | > Source |           |
|     | barriers")         |       |   | p |   | > and    |           |
|     |                    |       |   | o |   | > Date   |           |
|     |                    |       |   | n |   |          |           |
|     |                    |       |   | s |   |          |           |
|     |                    |       |   | e |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 1\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 1\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 1\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 1\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 1\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| **R |                    |       |   |   |   |          |           |
| esp |                    |       |   |   |   |          |           |
| ond |                    |       |   |   |   |          |           |
| to  |                    |       |   |   |   |          |           |
| ten |                    |       |   |   |   |          |           |
| (   |                    |       |   |   |   |          |           |
| 10) |                    |       |   |   |   |          |           |
| of  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| Hea |                    |       |   |   |   |          |           |
| lth |                    |       |   |   |   |          |           |
| Di  |                    |       |   |   |   |          |           |
| spa |                    |       |   |   |   |          |           |
| rit |                    |       |   |   |   |          |           |
| ies |                    |       |   |   |   |          |           |
| lis |                    |       |   |   |   |          |           |
| ted |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| F   |                    |       |   |   |   |          |           |
| orm |                    |       |   |   |   |          |           |
| 9   |                    |       |   |   |   |          |           |
| --  |                    |       |   |   |   |          |           |
| P   |                    |       |   |   |   |          |           |
| art |                    |       |   |   |   |          |           |
| A   |                    |       |   |   |   |          |           |
| .** |                    |       |   |   |   |          |           |
| Ple |                    |       |   |   |   |          |           |
| ase |                    |       |   |   |   |          |           |
| wr  |                    |       |   |   |   |          |           |
| ite |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| I   |                    |       |   |   |   |          |           |
| tem |                    |       |   |   |   |          |           |
| \#  |                    |       |   |   |   |          |           |
| f   |                    |       |   |   |   |          |           |
| rom |                    |       |   |   |   |          |           |
| F   |                    |       |   |   |   |          |           |
| orm |                    |       |   |   |   |          |           |
| 9   |                    |       |   |   |   |          |           |
| --  |                    |       |   |   |   |          |           |
| P   |                    |       |   |   |   |          |           |
| art |                    |       |   |   |   |          |           |
| A   |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| fi  |                    |       |   |   |   |          |           |
| rst |                    |       |   |   |   |          |           |
| c   |                    |       |   |   |   |          |           |
| olu |                    |       |   |   |   |          |           |
| mn, |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| c   |                    |       |   |   |   |          |           |
| orr |                    |       |   |   |   |          |           |
| esp |                    |       |   |   |   |          |           |
| ond |                    |       |   |   |   |          |           |
| ing |                    |       |   |   |   |          |           |
| Hea |                    |       |   |   |   |          |           |
| lth |                    |       |   |   |   |          |           |
| Dis |                    |       |   |   |   |          |           |
| par |                    |       |   |   |   |          |           |
| ity |                    |       |   |   |   |          |           |
| Fac |                    |       |   |   |   |          |           |
| tor |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| sec |                    |       |   |   |   |          |           |
| ond |                    |       |   |   |   |          |           |
| c   |                    |       |   |   |   |          |           |
| olu |                    |       |   |   |   |          |           |
| mn, |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| d   |                    |       |   |   |   |          |           |
| ata |                    |       |   |   |   |          |           |
| (   |                    |       |   |   |   |          |           |
| rat |                    |       |   |   |   |          |           |
| e/p |                    |       |   |   |   |          |           |
| erc |                    |       |   |   |   |          |           |
| ent |                    |       |   |   |   |          |           |
| /et |                    |       |   |   |   |          |           |
| c.) |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| tar |                    |       |   |   |   |          |           |
| get |                    |       |   |   |   |          |           |
| p   |                    |       |   |   |   |          |           |
| opu |                    |       |   |   |   |          |           |
| lat |                    |       |   |   |   |          |           |
| ion |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| th  |                    |       |   |   |   |          |           |
| ird |                    |       |   |   |   |          |           |
| c   |                    |       |   |   |   |          |           |
| olu |                    |       |   |   |   |          |           |
| mn, |                    |       |   |   |   |          |           |
| d   |                    |       |   |   |   |          |           |
| ata |                    |       |   |   |   |          |           |
| (   |                    |       |   |   |   |          |           |
| rat |                    |       |   |   |   |          |           |
| e/p |                    |       |   |   |   |          |           |
| erc |                    |       |   |   |   |          |           |
| ent |                    |       |   |   |   |          |           |
| /et |                    |       |   |   |   |          |           |
| c.) |                    |       |   |   |   |          |           |
| for |                    |       |   |   |   |          |           |
| c   |                    |       |   |   |   |          |           |
| omp |                    |       |   |   |   |          |           |
| ari |                    |       |   |   |   |          |           |
| son |                    |       |   |   |   |          |           |
| f   |                    |       |   |   |   |          |           |
| rom |                    |       |   |   |   |          |           |
| Nat |                    |       |   |   |   |          |           |
| ion |                    |       |   |   |   |          |           |
| al, |                    |       |   |   |   |          |           |
| Sta |                    |       |   |   |   |          |           |
| te, |                    |       |   |   |   |          |           |
| Cou |                    |       |   |   |   |          |           |
| nty |                    |       |   |   |   |          |           |
| or  |                    |       |   |   |   |          |           |
| ot  |                    |       |   |   |   |          |           |
| her |                    |       |   |   |   |          |           |
| es  |                    |       |   |   |   |          |           |
| tab |                    |       |   |   |   |          |           |
| lis |                    |       |   |   |   |          |           |
| hed |                    |       |   |   |   |          |           |
| rep |                    |       |   |   |   |          |           |
| ort |                    |       |   |   |   |          |           |
| ing |                    |       |   |   |   |          |           |
| a   |                    |       |   |   |   |          |           |
| rea |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| fou |                    |       |   |   |   |          |           |
| rth |                    |       |   |   |   |          |           |
| c   |                    |       |   |   |   |          |           |
| olu |                    |       |   |   |   |          |           |
| mn, |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| sou |                    |       |   |   |   |          |           |
| rce |                    |       |   |   |   |          |           |
| and |                    |       |   |   |   |          |           |
| d   |                    |       |   |   |   |          |           |
| ate |                    |       |   |   |   |          |           |
| for |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| d   |                    |       |   |   |   |          |           |
| ata |                    |       |   |   |   |          |           |
| for |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| tar |                    |       |   |   |   |          |           |
| get |                    |       |   |   |   |          |           |
| p   |                    |       |   |   |   |          |           |
| opu |                    |       |   |   |   |          |           |
| lat |                    |       |   |   |   |          |           |
| ion |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| fi  |                    |       |   |   |   |          |           |
| fth |                    |       |   |   |   |          |           |
| col |                    |       |   |   |   |          |           |
| umn |                    |       |   |   |   |          |           |
| and |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| sou |                    |       |   |   |   |          |           |
| rce |                    |       |   |   |   |          |           |
| and |                    |       |   |   |   |          |           |
| d   |                    |       |   |   |   |          |           |
| ate |                    |       |   |   |   |          |           |
| for |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| d   |                    |       |   |   |   |          |           |
| ata |                    |       |   |   |   |          |           |
| for |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| c   |                    |       |   |   |   |          |           |
| omp |                    |       |   |   |   |          |           |
| ari |                    |       |   |   |   |          |           |
| son |                    |       |   |   |   |          |           |
| d   |                    |       |   |   |   |          |           |
| ata |                    |       |   |   |   |          |           |
| in  |                    |       |   |   |   |          |           |
| the |                    |       |   |   |   |          |           |
| fi  |                    |       |   |   |   |          |           |
| nal |                    |       |   |   |   |          |           |
| c   |                    |       |   |   |   |          |           |
| olu |                    |       |   |   |   |          |           |
| mn. |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| I   | Health Disparity   | T     | C |   | > |          | > Source  |
| tem | Factor             | arget | o |   |   |          | > and     |
| \#  |                    | Popul | m |   | S |          | > date    |
|     |                    | ation | p |   | o |          | > for     |
|     |                    | data  | a |   | u |          | > c       |
|     |                    |       | r |   | r |          | omparison |
|     |                    |       | i |   | c |          | > data    |
|     |                    |       | s |   | e |          |           |
|     |                    |       | o |   | > |          |           |
|     |                    |       | n |   |   |          |           |
|     |                    |       | d |   | a |          |           |
|     |                    |       | a |   | n |          |           |
|     |                    |       | t |   | d |          |           |
|     |                    |       | a |   | > |          |           |
|     |                    |       |   |   |   |          |           |
|     |                    |       |   |   | d |          |           |
|     |                    |       |   |   | a |          |           |
|     |                    |       |   |   | t |          |           |
|     |                    |       |   |   | e |          |           |
|     |                    |       |   |   | > |          |           |
|     |                    |       |   |   |   |          |           |
|     |                    |       |   |   | f |          |           |
|     |                    |       |   |   | o |          |           |
|     |                    |       |   |   | r |          |           |
|     |                    |       |   |   | > |          |           |
|     |                    |       |   |   |   |          |           |
|     |                    |       |   |   | t |          |           |
|     |                    |       |   |   | a |          |           |
|     |                    |       |   |   | r |          |           |
|     |                    |       |   |   | g |          |           |
|     |                    |       |   |   | e |          |           |
|     |                    |       |   |   | t |          |           |
|     |                    |       |   |   | > |          |           |
|     |                    |       |   |   |   |          |           |
|     |                    |       |   |   | p |          |           |
|     |                    |       |   |   | o |          |           |
|     |                    |       |   |   | p |          |           |
|     |                    |       |   |   | u |          |           |
|     |                    |       |   |   | l |          |           |
|     |                    |       |   |   | a |          |           |
|     |                    |       |   |   | t |          |           |
|     |                    |       |   |   | i |          |           |
|     |                    |       |   |   | o |          |           |
|     |                    |       |   |   | n |          |           |
|     |                    |       |   |   | > |          |           |
|     |                    |       |   |   |   |          |           |
|     |                    |       |   |   | d |          |           |
|     |                    |       |   |   | a |          |           |
|     |                    |       |   |   | t |          |           |
|     |                    |       |   |   | a |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 2\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 2\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 2\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 2\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 2\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 2\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 2\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 2\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 2\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+
| 2\. |                    |       |   |   |   |          |           |
| ( ) |                    |       |   |   |   |          |           |
+-----+--------------------+-------+---+---+---+----------+-----------+

![](media/image1.wmf){width="1.4618055555555556in" height="0.23125in"}

##### FORM 10: ANNUAL EMERGENCY PREPAREDNESS AND MANAGEMENT (EPM) REPORT![](media/image2.wmf){width="1.7520833333333334in" height="0.23958333333333334in"}![](media/image2.wmf){width="1.2270833333333333in" height="0.16875in"} {#form-10-annual-emergency-preparedness-and-management-epm-report .unnumbered}

+-----------------------------------------------------------+----+----+
| **HEALTH CENTER EMERGENCY MANAGEMENT CONTACT**            |    |    |
+-----------------------------------------------------------+----+----+
| **Name:       Title:     **                               |    |    |
+-----------------------------------------------------------+----+----+
| **Address:     **                                         |    |    |
+-----------------------------------------------------------+----+----+
| **Land Phone:      Cell Phone:       Fax Phone:     **    |    |    |
+-----------------------------------------------------------+----+----+
| **E-mail:     **                                          |    |    |
+-----------------------------------------------------------+----+----+
| ***SECTION I - EMERGENCY PREPAREDNESS AND MANAGEMENT      | *  | ** |
| PLAN***                                                   | *Y | NO |
|                                                           | ES | ** |
| **Answer YES or NO to the following questions by marking  | ** |    |
| the appropriate box.**                                    |    |    |
|                                                           |    |    |
| **Provide the date if requested. Please explain all NO    |    |    |
| answers in Section III.**                                 |    |    |
+-----------------------------------------------------------+----+----+
| Has your Health Center conducted a thorough Hazards       |    |    |
| Vulnerability Assessment?                                 |    |    |
|                                                           |    |    |
| *If yes, the date completed:\_\_\_\_\_\_*                 |    |    |
+-----------------------------------------------------------+----+----+
| Does your Health Center have a written EPM plan?          |    |    |
|                                                           |    |    |
| ***If Yes, the date most recent EPM plan was approved by  |    |    |
| your Board*:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**          |    |    |
|                                                           |    |    |
| ***If No, skip to Health Center 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 health center attempted to participate    |    |    |
| with local/regional emergency planners?                   |    |    |
+-----------------------------------------------------------+----+----+
| Does the EPM plan address your capacity to render mass    |    |    |
| immunization/prophylaxis?                                 |    |    |
+-----------------------------------------------------------+----+----+
| ***SECTION II - HEALTH CENTER READINESS***                | *  | ** |
|                                                           | *Y | NO |
| **Answer YES or NO to the following questions. Please use | ES | ** |
| Section III for comments.**                               | ** |    |
+-----------------------------------------------------------+----+----+
| Does your Health Center 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 Health Center staff receive periodic training   |    |    |
| on disaster preparedness?                                 |    |    |
+-----------------------------------------------------------+----+----+
| Will the Health Center be required to deploy staff to     |    |    |
| non-Health Center sites/locations according to the        |    |    |
| emergency preparedness plan for the local community?      |    |    |
+-----------------------------------------------------------+----+----+
| Does your Health Center have arrangements with Federal,   |    |    |
| State, and/or local agencies for reporting of data?       |    |    |
+-----------------------------------------------------------+----+----+
| Does your Health Center have a back-up communication      |    |    |
| system? Internal?                                         |    |    |
|                                                           |    |    |
| External?                                                 |    |    |
+-----------------------------------------------------------+----+----+
|                                                           |    |    |
+-----------------------------------------------------------+----+----+
| Does your Health Center coordinate with other systems of  |    |    |
| care to provide an integrated emergency response?         |    |    |
+-----------------------------------------------------------+----+----+
| Has your Health Center been designated to serve as a      |    |    |
| point of distribution (POD) for providing antibiotics,    |    |    |
| vaccines, and medical supplies?                           |    |    |
+-----------------------------------------------------------+----+----+
| Has your Health Center implemented measures to prevent    |    |    |
| financial/revenue and facilities loss due to an           |    |    |
| emergency? (e.g. insurance coverage for short-term        |    |    |
| closure)                                                  |    |    |
+-----------------------------------------------------------+----+----+
| Does your Health Center have an off-site back up of your  |    |    |
| information technology system?                            |    |    |
+-----------------------------------------------------------+----+----+
| Does your Health Center have a designated EPM             |    |    |
| coordinator?                                              |    |    |
+-----------------------------------------------------------+----+----+

**FORM *10:* ANNUAL EMERGENCY PREPAREDNESSS AND MANAGEMENT (EPM)
REPORT**

+-----------------------------------------------------------------------+
| **SECTION III -- EXPLANATION OF NO ANSWERS/COMMENTS**                 |
|                                                                       |
| **Please provide and explanation of any "NO" answers. This section    |
| should also be used to provide details about your plan and/or         |
| comments regarding the health center's progress on EPM activities.**  |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

####### Appendix e: Primary Care Association, Primary Care Office, And National Organization Contacts {#appendix-e-primary-care-association-primary-care-office-and-national-organization-contacts .unnumbered}

##### PRIMARY CARE ASSOCIATION, PRIMARY CARE OFFICE,  {#primary-care-association-primary-care-office .unnumbered}

##### AND NATIONAL ORGANIZATION CONTACTS {#and-national-organization-contacts .unnumbered}

###### I. PRIMARY CARE ASSOCIATIONS {#i.-primary-care-associations .unnumbered}

ALABAMA

Al Fox

Executive Director

Alabama 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 of 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

Colorado 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/>

COLORADO

Julie Hulstein

Executive Director

Community Health Association Mountain/Plains States

600 Grant Street, Suite 800

Phone: 303/861-5165, ext. 226

Fax: 303/861-5315

Denver, Colorado 80203

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 Centers

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 Assn

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

Executive Director

Indiana Public Health Care Assn, 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 Primary Care Association

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>

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

Eml: [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 Community Health Centers

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 Assn of Community Health Centers

1113 E. Franklin Avenue, 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 Assn

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: <kgrantdavis@njpca.org>

[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, New York 10001\
Phone: 212/279-9686

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

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

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@orpca.org>

[http://www.orpca.org](http://www.orpca.org/)

PACIFIC BASIN

Clifford Chang

Executive Director

Pacific Islands Primary Care Assn

345 Queen Street, Suite 601

Honolulu, Hawaii 96813-4715

Tel: 808/536-8442 ext121\
Fax: 808/524-0347\
Email: <cchang@pacificislandspca.org>

PENNSYLVANIA

Henry Fiumelli

Executive Director

PA Forum for Primary Health Care

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, Puerto Rico 00927

Telephone: 787/758-3411

Fax: 787/758-1736

Email: <acsppr@coqui.net>

[**http://saludprimariapr.org**](http://saludprimariapr.org/)

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/)

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 Association 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, Bldg 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

Assn of Community Health Centers

2570 West 1700 South, Suite 153

Salt Lake City, Utah 84104

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

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 Assn of Community and Migrant Health Centers

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/>

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**](mailto:phil@wvpca.org)

[http://www.wvpca.org](http://www.wvpca.org/)

WISCONSIN

Stephanie Harrison

Executive Director

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

Executive Director

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 {#ii.-primary-care-offices .unnumbered}

[]{.mark}

[Alabama]{.underline}

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

Web site: [www.adph.org/opcrh](http://www.adph.org/opcrh)

PCO Director (Interim): Charles Graves -- <cgraves@adph.state.al.us>

HPSA Contact: Cleve Money -- <cmoney@adph.state.al.us>

NHSC Contact: Charles Graves -- <cgraves@adph.state.al.us>

[Alaska]{.underline}

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) 465-3091

Fax: (907) 465-6861

Web site:
<http://www.hss.state.ak.us/commissioner/healthplanning/primarycare/pc_home.htm>

PCO Director: Mark Millard -- <mark_millard@health.state.ak.us>
(907)465-8534

HPSA Contact: Alice Rarig -- <alice_rarig@health.state.ak.us> --
(907)465-1285

NHSC Contact: Nancy Barros -- <nancy_barros@health.state.ak.us>
(907)465-1491

[Arizona]{.underline}

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

PCO Director: Miriam Vega -- <vegami@azdhs.gov> -- (602)542-1436

NHSC Contacts: Fabian Valle -- <vallef@azdhs.gov> -- (602) 542-1066

Tanja James -- <jamest@azdhs.gov> -- (602) 542-1208

HPSA Contact: Colleen McGregor -- <mcgregc@azdhs.gov> -- (602)542-1219

[Arkansas]{.underline}

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: See individual contacts

Fax: (501) 280-4706

PCO Director and NHSC Contact: Bill Rodgers --
<William.rodgers@arkansas.gov> -- (501)280-4563

HPSA Contact: Randall Anderson -- <randall.anderson@arkansas.gov> --
(501) 280-4912

[California]{.underline}

Healthcare Workforce & Community Development Division

Office of Statewide Health Planning & Development

1600 9^th^ Street, Room 440

Sacramento, CA 95814

Phone: See individual contacts

Fax: (916) 654-3138

Web site: [www.oshpd.ca.gov](http://www.oshpd.ca.gov/)

PCO Director: Angela L. Minniefield - <aminnief@oshpd.ca.gov> -
(916)653-0733

HPSA and NHSC Contact: Konder Chung -- <kchung@oshpd.ca.gov> -- (916)
654-2884

[Colorado]{.underline}

Primary Care Office

Colorado Department of Public Health & Environment

4300 Cherry Creek Drive, South

Denver, CO 80246-1530

Phone: See individual contacts

Fax: (303) 758-3448

Web site:
[www.cdphe.state.co.us/pp/primarycare/index.html](http://www.cdphe.state.co.us/pp/primarycare/index.html)

PCO Director, NHSC and HPSA Contact: Kitty Stevens --
<kitty.stevens@state.co.us-> (303)692-2582

NHSC Contact: Carla Woolford -- <carla.woolford@state.co.us> --
(303)692-2348

[Connecticut]{.underline}

Connecticut Department of Public Health

410 Capitol Avenue, Mail stop #11 PSI

Hartford, CT 06134-0308

Phone: (860) 509-8074

Fax: (860) 509-8403

PCO Director: Felicia Epps -- <Felicia.epps@po.state.ct.us> -- (860)
509-8019

HPSA Contact: Marijane Mitchell -- <marijane.mitchell@po.state.ct.us> --
(860)509-7668

NHSC Contact: Lisa Davis -- <lisa.davis@po.state.ct.us> -- (860)509-8061

[Delaware]{.underline}

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

PCO Director, HPSA, and NHSC Contact: Kathy Collison --
<Katherine.collison@state.de.us>

[District of Columbia]{.underline}

District of Columbia Department of Health

Primary Health Services

825 N. Capital Street, NE, Room 4160

Washington, DC 20002

Phone: See individual contacts

Fax: (202) 535-1039

Web site: <http://doh.dc.gov/doh/site/default.asp>

PCO Director: David Rose -- <david.rose@dc.gov> - (202) 442-8984

HPSA and NHSC Contact: Yavonne Vaughan -- <yavonne.vaughan@dc.gov> --
(202) 442-9380

[Florida]{.underline}

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 (see individual extensions)

\(850\) 245-4446

Fax: (850) 922-6296

Web site:
[www.doh.state.fl.us/workforce/recruit1/index.html](http://www.doh.state.fl.us/workforce/recruit1/index.html)

PCO Director: Gail Underwood -- <gail_underwood@doh.state.fl.us> -
extension 2709

HPSA and NHSC Contact: Lisa Marsh -- <lisa_marsh@doh.state.fl.us> --
extension 2703

[Georgia]{.underline}

State Office of Rural Health

Georgia Department of Community Health

502 South 7^th^ Street

Cordele, GA 31015-4214

Phone: See individual contacts

Fax: (229) 401-3077

PCO Director: Charles Owens -- <cowens@dch.state.ga.us> - (229) 401-3090

Tony Brown -- <tbrown@dch.state.ga.us> -- (229)401-3086

HPSA Contact: Dave Hartin -- <dhartin@dch.state.ga.us> -- (229)401-3095

NHSC Contact: Peggy McMillan -- <pmcmillan@dch.state.ga.us> --
(229)401-3088

[Hawaii]{.underline}

State of Hawaii, Department of Health

Office of Planning Policy & Program Development

1250 Punchbowl Street, Room 340

Honolulu, Hawaii 96813

Phone: See individual contacts

Fax: (808) 586-4193

PCO Director: Valerie Yin - <valerie.yin@doh.hawaii.gov> - (808)586-4187

HPSA and NHSC Contact: Maile Burke -- <maile.burke@doh.hawaii.gov> --
(808)586-4188

[Idaho]{.underline}

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

Web site: http://www.healthandwelfare.idaho.gov/site/3459/

PCO Director, HPSA and NHSC Contact: Laura Rowen --
<rowenl@idhw.state.id.us>

[Illinois]{.underline}

Center for Rural Health

Illinois Department of Public Health

535 West Jefferson Street

Springfield, IL 62761

Phone: (217) 782-1624

Fax: (217) 782-2547

Web site: [www.idph.state.il.us](http://www.idph.state.il.us/)

PCO Director: Marcia Franklin -- <marcia.franklin@illinois.gov>

HPSA Contact: Nolan Nosari -- <nnosari@idph.state.il.us>

NHSC Contact: Julie Casper -- <julie.casper@illinois.gov>

[Indiana]{.underline}

Indiana State Department of Health

2 North Meridian Street, Suite 8-B

Indianapolis, IN 46204-3006

Phone: (317) 233-7846

Fax: (317) 233-7761

Web <http://www.in.gov/isdh/publications/llo/shortages/shortage.htm>

PCO Director, HPSA and NHSC Contact: Patrick Durkin
<–pdurkin@isdh.IN.gov>

[Iowa]{.underline}

Iowa Department of Public Health

Bureau of Health Care Access

Lucas State Office Building

321 East 12^th^ Street, 5^th^ Floor

DesMoines, IA 50319-0075

Phone: (515) 281-7223

Fax: (515) 242-6383

Web site: <http://www.idph.state.ia.us/hpcdp/primary_care.asp>

PCO Director, HPSA and NHSC Contact: Carl Kulczyk --
<ckulczyk@idph.state.ia.us>

[Kansas]{.underline}

Office of Local & Rural Health

Kansas Department of Health and Environment

1000 Southwest Jackson, Suite 340

Topeka, KS 66612

Phone: See individual contacts

Fax: (785) 296-1231

Web site: <http://www.kdhe.state.ks.us/olrh/pc.htm>

PCO Director and NHSC Contact: Barbara Gibson --
<bgibson@kdhe.state.ks.us> -- (785)296-0613

HPSA and NHSC Contact: Barbara Huske -- <bhuske@kdhe.state.ks.us> --
(785)296-2742

[Kentucky]{.underline}

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 (see individual extensions)

Fax: (502) 696-5231

Web site: <http://chfs.ky.gov/dph/ach/primarycare.htm>

PCO Director and NHSC Contact: John Hensley -- <john.hensley@ky.gov> --
extension 3773

HPSA Contact: Tammy Hutcherson -- <tammy.hutcherson@ky.gov> -- extension
3783

[Louisiana]{.underline}

Bureau of Primary Care and Rural Health

Louisiana Department of Health & Hospitals

1201 Capitol Access Road, 5^th^ Floor, or P.O. Box 2870

Baton Rouge, LA 70821-2870

Phone: See individual contacts Fax: (225) 342-5839

Web site:
[www.pcrh.dhh.louisiana.gov](http://www.pcrh.dhh.louisiana.gov/)

PCO Director and NHSC Contact: Gerrelda Davis -- <gdavis@dhh.la.gov> -
(225)342-1583

HPSA Contacts: Camille Turner -- <cturner@dhh.la.gov> -- (225)342-4702

Gayla Prentice -- <gprentic@dhh.la.gov> -- (225)342-0884

[Maine]{.underline}

Office of Rural Health & Primary Care

Maine Department of Health & Human Services

286 Water Street, Key Plaza

Augusta, ME 04333-0011

Phone: See individual contacts

Fax: (207) 287-5431

Web site: <http://www.maine.gov/dhhs/bohodr/orhpcpge.htm>

PCO Director and NHSC Contact: Charles Dwyer --
<charles.dwyer@maine.gov> - (207)287-3287

HPSA Contact: Marc Coulombe -- <marc.coulombe@maine.gov> --
(207)287-5504

[Maryland]{.underline}

Department of Health and Mental Hygiene

Primary Care Organization

201 West Preston Street

Baltimore, MD 21201

Phone: See individual contacts Fax: (410) 333-7501

PCO Director, HPSA and NHSC Contact: Antoinette Coward --
<cowarda@dhmh.state.md.us> -- (410)767-5602

[Massachusetts]{.underline}

Office of Primary Care

Massachusetts Department of Public Health

250 Washington Street, 5^th^ Floor

Boston, MA 02108-4619

Phone: See individual contacts

Fax: (617) 624-6062

PCO Director: Julia Dyck -- <julia.dyck@state.ma.us> -- (617)624-5224

HPSA Contact: Janice Healey -- <janice.healey@state.ma.us> --
(617)624-5942

NHSC Contact: Nicole Watson -- <Nicole.watson@state.ma.us> --
(617)624-6051

[Michigan]{.underline}

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: See individual contacts Fax: (517) 241-1200

PCO Director: Lonnie Barnett -- <barnettl@michigan.gov> -- (517)241-2963

HPSA Contact: Ian Horste - <horstei@michigan.gov> -- (517)241-9947

NHSC Contact: Steve Creamer -- <creamers@michigan.gov> -- (517)241-9946

[Minnesota]{.underline}

Office of Rural Health and Primary Care

Minnesota Department of Health

P.O. Box 64882

St. Paul, MN 55164-0882

Phone: See individual contacts Fax: (651) 297-5808

Web site: <http://www.health.state.mn.us/divs/chs/orh_home.htm>

PCO Director and NHSC Contact: Debra Jahnke --
<debra.jahnke@health.state.mn.us> -- (651)282-6334

HPSA Contact: Lee Schutz -- <Leona.schutz@health.state.mn.us> --
(651)282-3853

[Mississippi]{.underline}

Mississippi Department of Health

P.O. Box 1700

Jackson, MS 39215-1700

Phone: (601) 576-7216 Fax: (601) 576-7530

PCO Director, HPSA and NHSC Contact: Alvin Harrion --
<aharrion@msdh.state.ms.us>

NHSC Contact: Debra Powell -- <dpowell@msdh.state.ms.us>

[Missouri]{.underline}

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

Web site: [http://www.dhss.mo.gov](http://www.dhss.mo.gov/)

PCO Director: Harold Kirbey -- <harold.kirbey@dhss.mo.gov>

NHSC and HPSA Contact: Joanna Adamson -- <joni.adamson@dhss.mo.gov>

[Montana]{.underline}

Montana Primary Care Office

Montana Department of Public Health & Human Sciences

P.O. Box 202951

Helena, MT 59620-2951

Phone: See individual contacts Fax: (406) 444-7465

PCO Director: John Schroeck -- <jschroeck@mt.gov> -- (406)444-3934

HPSA and NHSC Contact: James Nybo --
[jnybo@mt.gov](mailto:jnybo@state.mt.us) -- (406)444-3574

[Nebraska]{.underline}

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

Web site: [www.hhss.ne.gov/orh](http://www.hhss.ne.gov/orh)

PCO Director, HPSA and NHSC Contact: Thomas Rauner --
[thomas.rauner@hhss.ne.gov](mailto:thomas.rauner@hhss.state.ne.us)

[Nevada]{.underline}

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

Web site: <http://health2k.state.nv.us/primary>

PCO Director and HPSA Contact: Mark Hemmings --
<mhemmings@nvhd.state.nv.us> -- (775)684-4041

NHSC Contact: Doug Schrauth -- <dschrauth@nvhd.state.nv.us> --
(775)684-4048

[New Hampshire]{.underline}

Rural Health and Primary Care

29 Hazen Drive

Concord, NH 03301

Phone: (603) 271-5934 Fax: (603) 271-4506

Web site:
[[http://www.dhhs.state.nh.us/DHHS/RHPC/pco.htm]{.underline}](http://www.dhhs.state.nh.us/DHHS/RHPC/pco.htm)

PCO Director, HPSA and NHSC Contact: Alisa Butler --
<agbutler@dhhs.state.nh.us>

[New Jersey]{.underline}

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

PCO Director, HPSA and NHSC Contact: Linda Anderson --
<linda.anderson@doh.state.nj.us>

[New Mexico]{.underline}

New Mexico Department of Health

625 Silver, SW, Suite 201

Albuquerque, NM 87102

Phone: See individual contacts Fax: (505) 841-5885

PCO Director: Kim Kinsey -- <kenbaht.kinsey@state.nm.us> --
(505)841-5871

Harvey Licht -- <Harvey.licht@state.nm.us> -- (505)841-5869

HPSA and NHSC Contact: Roxanne Konst <–Roxanne.konst1@state.nm.us> --
(505)841-5867

[New York]{.underline}

New York Department of Health

Tower Building, Room 1084

Empire State Plaza

Albany, NY 12237-0053

Phone: (518) 473-4700 Fax: (518) 474-0572

Web site: [http://www.nyhealth.gov](http://www.nyhealth.gov/)

PCO Director: Barry Gray -- <bmg01@health.state.ny.us>

HPSA and NHSC Contact: Caleb Wistar -- <ccw01@health.state.ny.us>

[North Carolina]{.underline}

Office of Research, Demonstrations and Rural Health Development

North Carolina Department of Health & Human Services

311 Ashe Avenue

Raleigh, NC 27606

Phone: See individual contacts Fax: (919) 733-8300

PCO Director: Serge Dihoff -- <serge.dihoff@ncmail.net> -- (919)715-7632

HPSA Contact: Mark Suggs -- <mark.suggs@ncmail.net> -- (919)733-2040,
ext. 221

NHSC Contact: Wanda Green -- <wanda.green@ncmail.net> -- (919)733-1777

[North Dakota]{.underline}

Office of Community Assistance

North Dakota Department of Health

600 E. Boulevard, Department 301

Bismarck, ND 58505-0200

Phone: See individual contacts Fax: (701) 328-1890

PCO Director: Gary Garland -- <ggarland@state.nd.us> -- (701)328-4839

HPSA Contact: Terry Lang -- <telang@medicine.nodak.edu> -- (701)858-6795

NHSC Contact: Mary Amundson -- <mamundson@medicine.nodak.edu> -
(701)777-4018

[Ohio]{.underline}

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: See individual contacts

Fax: (614) 995-4235

PCO Director: Coleen Schwartz -- <coleen.schwartz@odh.ohio.gov> --
(614)728-3700

HPSA Contact: Annette Oren -- <annette.oren@odh.ohio.gov> --
(614)466-7475

NHSC Contact: Geri Rousculp -- <geri.rousculp@odh.ohio.gov> --
(614)644-8496

[Oklahoma]{.underline}

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

PCO Director, HPSA and NHSC Contact: Mike Brown - <mikebr@health.ok.gov>

[Oregon]{.underline}

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

PCO Director: Joel Young -- <joel.young@state.or.us> -- (971)673-1269

HPSA and NHSC Contact: Nancy Abrams -- <nancy.g.abrams@state.or.us> --
(971)673-1228

[Pennsylvania]{.underline}

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

Web site:
[www.health.state.pa.us/pco](http://www.health.state.pa.us/pco)

PCO Director: Joseph May, III -- <jmay@state.pa.us>

HPSA Contacts: Barbara Bloom -- <bbloom@state.pa.us>

Diane Hergenrather -- <dhergenrat@state.pa.us>

NHSC Contact: Frederic Bowlan -- <fbowlan@state.pa.us>

[Puerto Rico]{.underline}

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

PCO Director, HPSA and NHSC Contact: Nadia Gardana --
<ngardana@salud.gov.pr> -- (787)274-6833

[Rhode Island]{.underline}

Office of Primary Care

Rhode Island Department of Health

3 Capitol Hill, Room 408

Providence, RI 02908

Phone: See individual contacts Fax: (401) 222-4415

Web site: [www.health.ri.gov](http://www.health.ri.gov/)

PCO Director and NHSC Contact: Mary Anne Miller --
<maryanne.miller@health.ri.gov> -- (401)222-7625

HPSA Contact: Carla Lundquist -- <carla.lundquist@health.ri.gov> --
(401)222-7626

[South Carolina]{.underline}

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

PCO Director, HPSA and NHSC Contact: Mark Jordan --
<jordanma@dhec.sc.gov>

[South Dakota]{.underline}

Office of Rural Health

South Dakota Department of Health

207 E. Missouri Avenue, #1A

Pierre, SD 57501

Phone: See individual contacts Fax: (605) 773-2680

Web site: [www.ruralhealth.sd.gov](http://www.ruralhealth.sd.gov/)

PCO Director: Bernard Osberg -- <bernie.osberg@state.sd.us> --
(605)773-3366

HPSA and NHSC Contact: Josie Petersen -- <josie.petersen@state.sd.us> --
(605)773-3517

[Tennessee]{.underline}

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

PCO Director, NHSC and Interim HPSA Contact: Patrick Lipford --
<patrick.lipford@state.tn.us>

[Texas]{.underline}

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

PCO Director, HPSA and NHSC Contact: Connie Berry --
<connie.berry@dshs.state.tx.us>

NHSC Contact: Harvey Browning -- <Harvey.browning@dshs.state.tx.us>

HPSA Contact: Rhonnda Jones -- <rhonnda.jones@dshs.state.tx.us>

[Utah]{.underline}

Office of Primary Care & Rural Health

Utah Department of Health

P.O. Box 142005

Salt Lake City, UT 84114-2005

Phone: See individual contacts Fax: (801) 538-6387

Web site: <http://health.utah.gov/primarycare>

PCO Director: Don Beckwith -- <dbeckwith@utah.gov> -- (801)538-6818

HPSA Contact: Shelly Phillips -- <shellyphillips@utah.gov> --
(801)538-6217

NHSC Contact: Erin Olsen -- [elolsen@utah.gov](mailto:eolsen@utah.gov)
-- (801)538-6214

[Vermont]{.underline}

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: See individual contacts Fax: (802) 651-1634

Web site: [www.healthyvermonters.org](http://www.healthyvermonters.org/)

PCO Director: Denis Barton -- <dbarton@vdh.state.vt.us> -- (802)951-4006

NHSC and HPSA Contact: Terry Fisher - <tfisher@vdh.state.vt.us> --
(802)951-5179

[Virgin Island]{.underline}

Virgin Islands Primary Health Care Office

Government House

21-22 Kongens Gade

St. Thomas, VI 00802

Phone: (340) 715-1611 Fax: (340) 715-3219

PCO Director, HPSA and NHSC Contact: Lorna Sutton --
<lornali96@earthlink.net>

[Virginia]{.underline}

Virginia Department of Health

Office of Health Policy and Planning

109 Governors Street, Suite 1016 East, 10^th^ Floor

Richmond, VA 23219

Phone: See individual contacts Fax: (804) 864-7440

PCO Director: Rene
Cabral-Daniels--<rene.cabraldaniels@vdh.virginia.gov>- (804)864-7425

Norma Marrin -- <norma.marrin@vdh.virginia.gov> -- (804)864-7430

HPSA and NHSC Contact: Norma Marrin -- <norma.marrin@vdh.virginia.gov>
-- (804)864-7430

[Washington]{.underline}

Office of Community & Rural Health

Washington State Department of Health

P.O. Box 47834

Olympia, WA 98504-7834

Phone: See individual contacts Fax: (360) 664-9273

Web site: [www.doh.wa.gov/hsqa/ocrh](http://www.doh.wa.gov/hsqa/ocrh)

PCO Director and NHSC Contact: Mary Looker -- <mary.looker@doh.wa.gov>
-- (360)236-2808

HPSA Contact: Laura Olexa -- <laura.olexa@doh.wa.gov> -- (360)236-2811

[West Virginia]{.underline}

Division of Primary Care

Office of Community and Rural Health Services

350 Capitol Street, Room 515

Charleston, WV 25301-3716

Phone: See individual contacts Fax: (304) 558-1437

Web site: <http://www.wvochs.org/dpc/>

PCO Director: David Haden -- <davidhaden@wvdhhr.org> -- (304)558-7127

HPSA Contact: Martha Endres -- <marthendres@wvdhhr.org> -- (304)558-4384

NHSC Contact: Melissa Wheeler -- <melissawheeler@wvdhhr.org> --
(304)558-4383

[Wisconsin]{.underline}

Bureau of Local Health Support & Emergency Medical Services

Division of Public Health

1 West Wilson Street, Room 118

Madison, WI 53701

Phone: See individual contacts Fax: (608) 261-6392

PCO Director and HPSA Contact: Larry Gilbertson --
<gilbelm@dhfs.state.wi.us> - (608)266-8154

NHSC Contact: Kathie Lenzen -- <lenzekl@dhfs.state.wi.us> --
(608)264-6528

[Wyoming]{.underline}

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

PCO Director: Lynne Weidel --
[lweide@state.wy.us](mailto:lweidel@state.wy.us) -- (307)777-6970

HPSA and NHSC Contact: Douglas Thiede -- <dthied@state.wy.us> --
(307)777-8651

[]{.mark}

###### III. NATIONAL ORGANIZATIONS {#iii.-national-organizations .unnumbered}

#####   {#section-14 .unnumbered}

Rachna Nivas

Program Coordinator, Technical Assistance Program

Association of Asian Pacific Community Health Organizations

300 Frank Ogawa Plaza, Suite 620

Oakland, CA 94612

Phone: 510-272-9536

Email: info@aapcho.org

www.aapcho.org

George E. Hardy, Jr., M.D., M.P.H

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: ghardy@astho.org

www.astho.org

Karen Mountain, R.N., M.S.N, M.B.A.

Executive Director

Migrant Clinicians Network, Inc.

1002 Land Creek Cove

Austin, TX 78746

Phone: 512-327-2017

Email: kmountain@migrantclinician.org

[www.migrantclinician.org](http://www.migrantclinician.org/)

John Schlitt, MSW

Executive Director

National Assembly for School-Based Health Centers\
666 11th Street, N.W., Suite 735

Washington, DC 20001

Phone: 202-638-5872

Email: jschlitt@nasbhc.org

[www.nasbhc.org](http://www.nasbhc.org/)

Pamela J. Byrnes, PhD

Managed Growth Assistance Program

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

Executive Director

National Center for Farmworker Health

1770 FM 967

Buda, TX 78610

Phone: 512-312-2600

Email: [www.ncfh.org](http://www.ncfh.org/)

<ryder@ncfh.org>

Karen Rotondo

New Access Coordinator

National Healthcare for the Homeless Council

1716 Greenwood Avenue/P.O. Box 60427

Nashville, TN 37206-0427

Phone: 508-775-4375

Email: kerotondo@aol.com

[www.nhchc.org](http://www.nhchc.org/)

Rosemary McKenzie

Project Director

National Rural Health Association

One West Armour Boulevard, Suite 203

Kansas City, MO 64111-2087

Phone: 816-7563140

Email: <rmckenzie@nrharural.org>

[www.nrharural.org](http://www.nrharural.org/)

########  {#section-15 .unnumbered}

####### Appendix F: Definitions For New Access Point Applications {#appendix-f-definitions-for-new-access-point-applications .unnumbered}

##### DEFINITIONS FOR NEW ACCESS POINT APPLICATIONS  {#definitions-for-new-access-point-applications .unnumbered}

**ALTERATION/RENOVATION:** Alteration and renovation (A&R) is defined as
work required to change the interior arrangements or other physical
characteristics of an existing facility or installed equipment so that
it may be more effectively utilized for its currently designated purpose
or adapted to an alternative use to meet a programmatic requirement. A&R
costs that do not constitute construction are allowable charges to PHS
supported projects and activities. Section 330 grant funds may not be
used to support construction of facilities

**BUDGET PERIOD**: is each 12-month period within an approved project
period (see below for definition).

**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 HRSA 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 to Health Centers 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.

**DISCOUNTS:** are provided to self-pay patients based on their ability
to pay. Those at or below 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. Those
over 200% of poverty may not receive a discount supported by HRSA.

**ENABLING SERVICES**: See Required Primary Care Services below.

**ENCOUNTER:** Encounters are a documented, face-to-face contact between
a user 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.

**FULL OPERATIONAL CAPACITY:** relates to the projected number of
providers and patients within the designated target population that the
center can realistically serve after two years of Federal funding of the
project. This capacity should be determined using the projected provider
levels required by the center to operate at its full level of services
(i.e., at the

full-range of services required by section 330 statute, regulations and
Health Center Program Expectations). **It is expected that full
operational capacity will be achieved within 2 years of receiving
Federal section 330 support and that the third year of funding will
represent the project at full operational capacity for a 12-month period
of time.**

Full operational capacity for a center can be calculated based on the
projected staffing levels for the new access point(s). In general
applicants may wish to use a physician to population ratio of 1:1,500 as
a guide to calculate their appropriate full operational patient
capacity. For midlevel practitioners (e.g., nurse practitioners,
physician assistants, and certified nurse midwives), applicants may use
a 1:750 provider to patient ratio. For example, a practice with a team
of two full-time physicians and a full-time nurse practitioner would
have a full operational capacity of 3 full-time equivalent (FTE)
providers and 3,750 patients.

In general, it is recommended that providers be available to provide
services to patients as appropriate and reasonable based on the
population and service delivery plan proposed (e.g., proposed services,
site capacity, etc.)

**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 is a supervised
public or private facility that provides temporary accommodations and an
individual who is a resident in transitional housing.

**MIGRATORY AND SEASONAL AGRICULTURAL WORKERS:** Migratory agricultural
worker means an individual whose principal employment is in agriculture,
who has so been employed within 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 migratory agricultural
worker.

**NEW ACCESS POINT:** A new access point is a new delivery site for the
provision of comprehensive primary and preventive health care services.
The two types of new access points referenced in this application
guidance are (1) new starts and (2) satellites. (These are described
below.) Every competitive new access point will demonstrate compliance
with the applicable requirements of section 330 of the PHS Act, the
implementing regulations and HRSA Program Expectations. To be
competitive, new access point applications will:

> \(a\) demonstrate that all persons will have ready access to the full
> range of required primary, preventive, enabling (see definition above)
> and supplemental health services, including oral health care, mental
> health care and substance abuse services, either directly on-site or
> through established arrangements without regard to ability to pay;
>
> \(b\) demonstrate compliance at the time of application (or a plan for
> compliance within 120-days of a grant award) with the requirements of
> section 330, its guidelines and regulations;
>
> \(c\) demonstrate how section 330 funds will expand services and
> increase the number of people served through the establishment of a
> new service delivery site(s) and/or at an existing site(s) not
> currently within a HRSA funded scope of project;
>
> \(d\) demonstrate that the site(s) will be operational and services
> will be initiated within 120 days of a grant award; and
>
> \(e\) demonstrate how section 330 funds will augment already available
> funds and in-kind resources to expand existing primary health care
> service capacity to currently underserved populations.

**NEW STARTS:** A new start applicant is an organization that
**currently DOES NOT RECEIVE** Federal grant support under the
Consolidated Health Center Program authorized under section 330 of the
PHS Act. A new start application should address the entire scope of the
project being proposed for Federal support. New start applicants may
submit an application for Federal support for a single site or a
multi-site operation and may request funding for one or multiple types
of health centers authorized under section 330 based on the
population(s) to be served.

**PRIMARY CARE SERVICES**: See Required Primary Care Services below.

**PROJECT PERIOD:** is defined as the total time for which Federal grant
support has been approved. For existing grantees, a project period may
be up to five years in length. For new organizations, a project period
may be up to three years in length.

**REQUIRED PRIMARY CARE SERVICES**: Section 330 of the Public Health
Services 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.

**SATELLITES:** A satellite applicant is an organization **that
CURRENTLY RECEIVES grant support under the Consolidated Health Center
Program authorized under section 330 of the PHS Act.** All satellite
applicants must propose to establish a new access point(s) to serve a
new patient population that is outside the applicant's approved scope of
project (i.e., not listed on the applicant's most recently submitted
Exhibit B "Service Sites" from the continuation application or Change in
Scope request under any section 330 program). A satellite application
should address **ONLY** the service area and target population of the
proposed new access point(s) (i.e., only the new site(s) and service
area proposed in the satellite application, not all of the sites or the
entire service area of the applicant) in terms of need, population to be
served and the new delivery system being proposed. Satellite applicants
may submit an application for Federal support to establish a single new
access point or multiple access points (outside of their approved scope
of project under any section 330 program) and may request funding for
one or multiple types of health centers authorized under section 330
based on the population(s) to be served. Satellite applicants may not
request funding to support the expansion/addition of
services/programs/staff at a site(s) that is currently listed as being a
part of their approved scope of project under the Consolidated Health
Center Program.

**SCOPE OF PROJECT:** is a description of the health center's total
approved project, specifically defining the services, sites, providers,
target population(s), and service area(s) which are in compliance with
all section 330 requirements. Grant funds may or may not be used in
sites included in the scope of project. This total project includes
program income and other non-section 330 funds.

**SERVICE AREA:** is defined as a geographic area with precise
boundaries that is federally-designated, in whole or in part, as a MUA
or a MUP. The size of the service area should be appropriate to provide
services in a timely and appropriate fashion. Within the service area,
barriers to care should be overcome to the extent possible and the
applicant must provide access to anyone who seeks services. The
delineation of the service area should conform to relevant boundaries
(such as political subdivision, school districts, health and social
service programs) and should include a description of the service area
population.

**SERVICE SITE:** A service site is any location in the health center's
service area where a health center, either directly or through
established arrangements, provides primary health care services within
its scope of services to a medically underserved area or population.
Service sites are defined as locations where all of the following
conditions are met:[^2]

-   health center encounters are generated by documenting in the medical
    record face-to-face contacts between patients and health center
    providers;

-   health center providers exercise independent judgment in the
    provision of services to the patient;

-   services are provided directly by or on behalf of the health center,
    whose governing board retains control and authority over the
    provision of the services; and

-   services are provided on a regularly scheduled basis (e.g., daily,
    weekly). However, there is no minimum number of hours per week that
    services must be available.

The name and address of each site at which the health center provides
care that meets the definition above must be listed in Form 5 -- Part B:
Service Sites, to be considered for inclusion in the scope of project.
Neither administrative offices nor supportive/ancillary service
locations that do not provide direct health care services are considered
service sites. Examples of specific service sites to be listed on Form 5
-- Part B, requiring full names and addresses include:

-   Any full-time or part-time clinic location including health centers
    located in migrant camps, shelters, schools, and other
    community-based sites.

There are other service delivery sites that do not require full names
and addresses to be listed on Form 5 -- Part B. These are "multiple
location" sites. Health Centers may list the type of location in Form 5
-- Part B, rather than each individual location. As appropriate for the
new access point application, multiple location sites should be
described in the grant application. Examples of "multiple location"
sites to be listed on Form 5 -- Part B, without specific addresses, but
using "multiple locations" include:

-   A mobile van that provides primary care services at multiple
    locations on a defined schedule. The locations where the van
    provides the services do not need to be listed as sites, but the
    category of "mobile van" should be listed.

-   If a health center provides immunizations once a month at 15
    different day care centers, the category "day care center" should be
    listed rather than including the names of the individual day care
    centers.

-   Patients' homes, if it is the policy of the health center that
    providers will make home visits to enrolled health center patients.

The health center may also provide supportive or ancillary services that
do not generate encounters, at locations other than the service site.
These locations should be listed on Form 5 -- Part C: Other
Activities/Locations. As appropriate for the new access point
application, multiple location sites should be described in the grant
application. Examples of these services include, but are not limited to:

-   filling prescriptions.

-   taking X-rays.

-   performing street outreach.

-   providing health education.

-   participating in health fairs.

**SLIDING DISCOUNT:** the percent discount is 100% for persons at or
below the poverty level and 0% for those over 200% of the Federal
poverty level. Organizations 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.

**SPARSELY POPULATED RURAL AREAS:** Given the unique needs of sparsely
populated frontier areas, preference will be given to new access point
applications from these areas. Organizations applying under the sparsely
populated frontier areas classification should describe their proposed
service area in terms of population density and must provide
documentation clearly demonstrating their **ENTIRE proposed service
area** is classified as sparsely populated (i.e., geographic area with 7
or less people per square mile).

In terms of project plan requirements, 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, health centers 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 (section
330(k)(3)(H)) under section 330(k)(3)(H)(iii). However, such applicants
must clearly demonstrate why the governing board requirements cannot be
met and must provide a documented plan for soliciting community input in
the development and operation of the new service delivery site. Under
section 330(p), sparsely populated area applicants may also receive
waivers regarding the mandatory provision of all required services and
the collection of certain fees.

**STRATEGIC PLANNING:** Sets the course for the organization's future
based on market and internal information.

**SUB-RECIPIENT:** is an organization that receives a sub-award from the
section 330 grantee. In a sub-recipient relationship, each organization
(grantee and sub-recipients) must be in compliance with all applicable
section 330 requirements.

**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 center\'s service delivery plan. The target population
for a center may be composed of a particular ethnic/socio-economic group
or may be composed of a variety of different ethnic/socio-economic
groups. A target population may also be a sparsely populated rural or
frontier area. It may not, however, be limited in terms of age or
gender.

-   **For CHCs** target population refers to the individuals within the
    service area to whom the center will direct its service delivery
    plan.

-   **For MHCs** the target population refers to the migratory and
    seasonal farmworkers and their families within the service area to
    whom the center will direct its service delivery plan.

-   **For HCHs** the target population refers to the homeless
    individuals within the service area to

-   whom the center 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 as
    appropriate.

All health centers 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 health center\'s current
service delivery capacity.

**USER/PATIENT:** Users (Patients) are individuals who have at least one
encounter during the year within the scope of activities supported by
any HRSA grant. Users do not include individuals who only have
encounters such as outreach, community education services, and other
types of community-based services not documented on an individual basis.
Also, persons who only receive services from large-scale efforts such as
mass immunization programs, screening programs, and health fairs are not
users. Persons whose only contact with the grantee is to receive WIC
counseling and vouchers are not users and the contact does not generate
an encounter.

[^1]: While section 330 (b)(1)(B) allows MHC organizations to provide
    certain required primary health services on a seasonal basis, all
    applicants are expected under sections 330(k)(2)(C) and 330(k)(3)(A)
    to demonstrate that the project will maximize availability, access,
    and continuity of the required services to populations within the
    service area. Therefore, applicants proposing a part-time delivery
    site must demonstrate that the project will maximize access to
    services for the target population given the community's needs and
    barriers as presented in the application.

[^2]: Service sites are a critical component of a health center's scope
    of project. Sites are also used by other programs, e.g., FTCA, 340B
    and FQHC, in determining eligibility for the benefits available
    through these programs. Each of these programs has a specific
    application process and a comprehensive set of requirements, of
    which service site is only one. In other words, inclusion in scope
    of project is necessary, but not sufficient to ensure participation
    in the other programs. To participate, all of the requirements of
    the other programs must be met and coordination with these programs
    is required.