**U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**Health Resources and Services Administration**

*Bureau of Primary Health Care*

**PROGRAM GUIDANCE**

Fiscal Year 2006

**Application Due Date: December 15, 2005**

**Date of Issuance: *November 1, 2005***

*Guidance contact:*

Kirsten Argueta

Public Health Analyst

Division of Policy and Development

Bureau of Primary Health Care

Telephone: (301) 594-4300

Fax: (301) 594-4997

Authority: Public Health Service Act, Section 330, 42 U.S.C. 254b. (as
amended)

**Executive Summary**

This application guidance details the expectations, eligibility
requirements, review criteria, and awarding factors for existing section
330 supported health centers seeking supplemental grant support to
expand medical capacity in fiscal year (FY) 2006. The goal of this
funding opportunity is to expand access to primary health care services
by increasing penetration into a health center's current service area to
improve the health status of people in those areas (i.e., significantly
increasing the number of medical users served by existing health center
grantees).

This application guidance supersedes Program Information Notice (PIN)
2005-02. For FY 2006, the following differences should be noted:

\- New application due dates, review and award timelines have been
established.

> \- Review criteria have been modified.
>
> \- Eligibility criteria have been updated.

-   Readiness requirements have been modified.

-   Definition of significant increase in new users has been updated.

-   Directions for electronic submission have been updated.

-   School Based Health Centers (SBHC) are no longer identified as a
    separate section 330 program/type.

Although action on the FY 2006 appropriation for the Consolidated Health
Center Program has not been completed, the Bureau of Primary Health Care
(BPHC) anticipates that funds will be available to accept applications
from organizations seeking a grant for expanded medical capacity under
the Consolidated Health Center Program (i.e., Community Health Centers
(CHC) including those previously identified as School Based Health
Centers (SBHC), Migrant Health Centers (MHC), Health Care for the
Homeless (HCH), and Public Housing Primary Care (PHPC)) supported by
grant funding authorized by section 330 of the Public Health Service
Act, as amended.

It is the responsibility of the applicant to ensure that the complete
application is postmarked or submitted electronically by 5:00 P.M. ET on
December 15, 2005. Applications postmarked or submitted electronically
by the published due date will be reviewed, with funding decisions
announced on or about June 1, 2006. Applications postmarked or submitted
after the due date/time will not be accepted for processing and will be
returned.

**All applicants requesting EMC funds must use this guidance.** The
guidance should be reviewed thoroughly prior to making a decision to
apply.

Questions regarding the application and review process described in this
guidance may be directed to Kirsten Argueta in the Division of Policy
and Development at <kargueta@hrsa.gov> or 301-594-4300.

# Guidance Table of Contents

[Guidance Table of Contents 3](#guidance-table-of-contents)

[I. Funding Opportunity Description
3](#i.-funding-opportunity-description)

[Purpose 3](#__RefHeading___Toc117398374)

[Definition of Significant Increase in New Users
3](#definition-of-significant-increase-in-new-users)

[Time-Limited State Funded Programs
3](#time-limited-state-funded-programs)

[Background 3](#background)

[Other Program Requirements and Expectations
3](#other-program-requirements-and-expectations)

[Consolidated Health Center Program
3](#consolidated-health-center-program)

[Replacement Sites 3](#replacement-sites)

[Mobile Vans 3](#mobile-vans)

[Technical Assistance 3](#technical-assistance)

[II. Award Information 3](#ii.-award-information)

[Type of Award 3](#type-of-award)

[Summary of Funding 3](#summary-of-funding)

[Maximum Grant Support 3](#maximum-grant-support)

[III. Eligibility Information 3](#iii.-eligibility-information)

[1. Eligible Applicants 3](#eligible-applicants)

[2. Cost Sharing/Matching 3](#cost-sharingmatching)

[3. Other 3](#other)

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

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

[Application Materials 3](#application-materials)

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

[Application Format Requirements 3](#application-format-requirements)

[Application Format 3](#application-format)

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

[4. Intergovernmental Review 3](#intergovernmental-review)

[5. Funding Restrictions 3](#funding-restrictions)

[6. Other Submission Requirements 3](#other-submission-requirements)

[Electronic Submission 3](#electronic-submission)

[Paper Submission 3](#paper-submission)

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

[1. Review Criteria 3](#review-criteria)

[2. Review and Selection Process 3](#review-and-selection-process)

[Funding Preferences 3](#funding-preferences)

[Other Awarding Factors 3](#other-awarding-factors)

[3. Anticipated Announcement and Award Date
3](#anticipated-announcement-and-award-date)

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

[1. Award Notices 3](#award-notices)

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

[3. Reporting 3](#reporting)

[4. Performance Review 3](#performance-review)

[VII. Agency Contacts 3](#vii.-agency-contacts)

[VIII. Other Information 3](#viii.-other-information)

[Contact Information for Application Development Assistance
3](#contact-information-for-application-development-assistance)

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

[[Attachment 1: Program Specific Forms]{.smallcaps}
3](#attachment-1-program-specific-forms)

[FORM 1 - PART A:](#form-1-part-a) [GENERAL INFORMATION WORKSHEET - FY
2006 EMC 3](#general-information-worksheet---fy-2006-emc)

[FORM 1 - PART B: BPHC FUNDING REQUEST SUMMARY -- FY 2006 EMC
3](#form-1---part-b-bphc-funding-request-summary-fy-2006-emc)

[FORM 2 - INCOME ANALYSIS FORMAT -- FY 2006 EMC (Page 1 of 2)
3](#form-2---income-analysis-format-fy-2006-emc-page-1-of-2)

[Instructions for Completing Form 2: Income Analysis
3](#__RefHeading___Toc117398423)

[[Attachment 2: Format for the Line Item Budget
Justification]{.smallcaps}
3](#attachment-2-format-for-the-line-item-budget-justification)

[Line-Item Budget Justification \[Required Format\]
3](#line-item-budget-justification-required-format)

[[Attachment 3: Service Delivery Plan and Business Plan]{.smallcaps}
3](#attachment-3-service-delivery-plan-and-business-plan)

[Guidelines For Developing the](#guidelines-for-developing-the) [Service
Delivery Plan and the Business Plan
3](#service-delivery-plan-and-the-business-plan)

[Format for
the](#format-for-the-service-delivery-plan-business-plan-presentations)
[Service Delivery Plan & Business Plan Presentations
3](#format-for-the-service-delivery-plan-business-plan-presentations)

**PUBLIC BURDEN STATEMENT:** An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless
it displays a currently valid OMB control number. The OMB control number
for this project is 0915‑0285. Public reporting burden for the applicant
for this collection of information is estimated to average 100 hours,
including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to HRSA Reports
Clearance Officer, 5600 Fishers Lane, Room 14-45, Rockville, Maryland,
20857.

# I. Funding Opportunity Description

## Purpose

President Bush's fiscal year (FY) 2006 budget proposes an increase of
approximately \$303 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. The appropriation
increase represents the fifth and final installment in the President's
Health Centers Initiative to serve millions of additional people in the
Nation's neediest communities. 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.

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
sites over five years. The Expanded Medical Capacity (EMC) grant
opportunity assists in achieving this goal, by supporting the expansion
of sites that significantly increase the provision of comprehensive
primary and preventive health care services in areas of high need. The
increased access to primary health care services will also improve the
health status and decrease health disparities of the medically
underserved populations to be served.

In FY 2006, the Bureau of Primary Health Care (BPHC) will accept EMC
applications from the following types of existing health centers
currently receiving support under the Consolidated Health Center
Program:

> \- Community Health Centers (CHC)[^1] - 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 purpose of this guidance, the term "health center" refers to the
diverse types of health centers (i.e., CHC, MHC, HCH, and PHPC) that are
authorized under section 330 of the PHS Act. This document provides
detailed information on the expectations, eligibility requirements,
review criteria and awarding factors for these supplemental awards. The
goal of the EMC program is to increase and expand access to primary
health care services by increasing penetration into a health center's
current service area, to improve the health status of people in those
areas and to decrease health disparities within the service area.

For the purpose of this application guidance, EMC sites are defined as
service delivery sites **within a health center's current approved scope
of project** (i.e., listed on a grantee's most recently approved Form
5-Part B/Exhibit B from a service area competition, approved change in
scope, or a non-competing continuation application), which are being
expanded to significantly increase access to primary health care
services to underserved populations in communities where the health
center's ability to provide care falls short of meeting the need for
services. **EMC funds may not be used to expand capacity at sites
operated outside of a grantee's current approved scope of project.** EMC
funds may not be used to establish new sites, nor to expand non-medical
services except as noted under *Other Program Requirements and
Expectations* on page [7](#other-program-requirements-and-expectations).

Strategies for expanded medical capacity may include but are not limited
to expanding existing primary care medical services, adding new medical
providers where excess facility capacity exists, expanding hours of
operations, or providing additional medical services through contractual
relationships (e.g., obstetrics and gynecology services) at an existing
health center site.

EMC applications should demonstrate 1) that the EMC proposal will
increase access to comprehensive primary and preventive health care and
improve the health status of underserved and vulnerable populations, and
2) that the EMC proposal 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 to all individuals in
the service area.

### Definition of Significant Increase in New Users

All EMC applicants must ensure that proposed strategies will result in a
significant increase in the number of health center users served by
existing delivery sites as defined below. (As previously noted, all
organizations receiving section 330 funds to support health centers
located in schools are considered CHCs and, therefore, must follow the
requirements for CHCs described below).

1.  Health centers that propose to expand medical capacity of an
    **existing CHC program,** regardless of whether EMC funding is also
    requested to serve a special population(s) (i.e., MHC, HCH, PHPC
    programs), must demonstrate growth in the form of:

> A minimum increase in users of **25 percent of the total number of
> users** for the organization reported in the CY 2004 UDS, **or 3000
> new users** -- whichever is less;

2.  MHC, HCH and/or PHPC *only* health centers that propose to expand
    medical capacity by **initiating a CHC program for the first time**
    must demonstrate growth in the form of:

> A minimum increase of **3000 new users;**

3.  Health centers that propose to expand medical capacity by
    **initiating or expanding *only* a MHC, HCH, and/or PHPC program,
    AND DO NOT also include a request for new or additional CHC
    funding**, must demonstrate growth in the form of:

> A minimum increase in users of **10 percent of the total number of
> users** for the organization reported in the calendar year (CY) 2004
> Uniform Data System (UDS), **or 1000 new users** -- whichever is less.

Note: Applicants must indicate the type of health center funding
requested on Form 1-A and Form 1-B (provided in Attachment 1: Program
Specific Forms of this guidance).

### Time-Limited State Funded Programs

The BPHC recognizes that a few States have implemented time-limited
programs to support the development and initial operations of health
centers that propose to increase access to primary care services (i.e.,
incubator programs, State-funded start up funds). Through the EMC
program, the BPHC will allow for the coordination of these State
programs and the President's Initiative, and will enable the
continuation of these expansion efforts. As a result, a significant user
increase for centers that can document successful participation in such
time-limited State programs will be defined as 50 percent of the
applicable eligibility requirement set forth above (e.g., CHCs in such
State-funded programs will be deemed eligible by meeting the lesser of
12.5 percent or 1,500 new users). The applicant must also demonstrate
that the expansion efforts supported by the State program prior to an
EMC award, in addition to expansion efforts subsequent to an EMC award,
will result in combined outcomes that are equal to or greater than 100
percent of the applicable eligibility requirement. **Information
regarding the successful participation in such State funded programs
must be included on the FORM 1-A, General Information Worksheet (see
page [39](#form-1-part-a)), and in the Evaluative Measures section of
the program narrative (see page [30](#_Ref84836880)).** Applicants
should document the center's progress toward meeting the initial goals
and objectives under the State funded program, and the additional goals
resulting from the receipt of EMC grant funding.

## Background

The mission of the BPHC 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 the BPHC are focused toward 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. The BPHC 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.). Currently there are 955 federally funded health centers with
more than 3,700 primary care service sites located in urban and rural
underserved areas throughout the U.S. and its territories. Approximately
13.2 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**.**

## Other Program Requirements and Expectations

**EMC applicants must propose to expand medical capacity at sites within
the health center's current approved scope of project** in communities
where the health center's ability to provide care falls short of meeting
the need for services. In other words, at the time of application
submission, the sites proposed for a medical expansion must be listed on
the applicant's most recently approved Form 5-Part B/Exhibit B from a
service area competition, change in scope, or non-competing continuation
application. Applicants are expected to present a sound and complete
plan for the successful expansion of their medical capacity that
demonstrates responsiveness to the identified needs of the target
population within the existing service area. EMC applications must
demonstrate a significant increase in penetration into underserved
communities or populations.

EMC applicants must also demonstrate **readiness** to initiate the
proposed project, i.e., proposed staff recruited and services provided
to the community within 120 days of receiving the grant award. However,
BPHC will consider on a case-by-case basis a future request to extend
the expected operational date for good cause.

Applicants are also expected to present a reasonable and appropriate
budget(s) based on the activities proposed in the project plan and
business plan. It is understood that the operating budgets of health
centers are comprised of many revenue streams, some of which can be time
limited. The proposed budget should be based on an appropriate increase
in medical users, at least the required minimum number of new users to
be served (refer to guidelines in the Definition of Significant Increase
in New Users section on page
[6](#definition-of-significant-increase-in-new-users)) and the expanded
medical services to be provided at the EMC site(s).

EMC applicants are expected to demonstrate the extent to which the EMC
award will increase the number of people served, the number of primary
medical care providers made available to the population, and penetration
into the existing service area. As a point of reference, it is
anticipated that, on average, applicants may propose to hire three
additional full time equivalent (FTE) medical providers to address the
significant growth in medical capacity. For the purposes of this
guidance, primary care medical providers include primary care
physicians, nurse practitioners, physician assistants, and certified
nurse midwives. It is important to note that this definition of primary
care medical providers **does not** include oral health (OH), or mental
health and substance abuse (MH/SA) service providers. Mental health and
substance abuse services providers can be included in the EMC scope only
where necessary to support medical providers when mental health and
substance abuse problems are prevalent in the new populations being
served.

Applicants should describe their systems that ensure participation of
the diverse cultures in their communities, including participation of
persons with limited English-speaking ability, in programs offered by
the health center. Applicants must demonstrate that the proposed
clinical staffing pattern (e.g., number and mix of primary care
physicians and other providers and clinical support staff, linguistic
and cultural competency, etc.) is appropriate for the level and mix of
services to be provided.

### Consolidated Health Center Program

All applicants are expected to demonstrate continued compliance with the
applicable requirements of section 330 of the PHS Act and BPHC
guidelines, including the Health Center Program Expectations (Program
Information Notice 98-23). Community Health Centers and/or Migrant
Health Centers are also expected to demonstrate compliance with the
implementing regulations (42 CFR 51c and 42 CFR 56, respectively). 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.

For applicants seeking funding to expand to serve populations for which
they do not currently receive Federal support, it is important that the
proposal adequately exhibit the awareness of the appropriate
organizational changes (i.e., statutory or other) that may be necessary
to assure compliance and the ability of the organization to implement
these changes. Areas of consideration should include representation in
governance, modifications to clinical and business systems, additional
enabling services and overall cultural competency. In the
Resources/Capabilities section of the narrative, these applicants are
required to identify the changes necessary to comply with all relevant
program requirements to receive grant funds for services targeted to the
proposed populations. The application must also certify that the
organization will be brought into compliance upon receipt of grant
funding, and include information exhibiting the applicant's ability to
do so.

Please note that in previous documents, application guidances and other
materials, HRSA has made reference to the School-Based Health Center
(SBHC) Program. Section 330 of the PHS Act does not include
authorization for a SBHC Program. Therefore, HRSA will no longer
identify SBHCs as a separate Health Center Program or category/type of
health center; however, there will continue to be recognition of
school-aged children as an underserved population served by health
centers. All organizations receiving section 330 funding specifically to
support a SBHC must comply with the requirements of section 330(e),
Community Health Center Program. Funds to support the SBHC should be
identified or included in budget presentations as a request for section
330(e), CHC Program funding.

All applicants must include information about how the health center
governance requirements are being addressed and how the governance may
be impacted by the proposed expansion (i.e., adding additional
representation from the area/population to be served). Organizations
that currently receive funding under *only section 330(g), section
330(h) and/or section 330(i)* and propose to expand services only to
migratory and seasonal farmworkers, homeless populations or public
housing residents, as applicable, may continue to receive a waiver for
all or some of the governance requirements, as appropriate. If the
application proposes to expand capacity to serve a new population and,
if a waiver has been granted for all or some of the governance
requirements, the waiver request must be amended to reflect the new
population served and a description of the reasons for the amended
waiver and the alternative mechanism being proposed to ensure consumer
input is in compliance with guidelines as described in PIN 98-12. The
amended waiver request should be submitted as a letter with the
application.

For organizations that currently receive funding under *only section
330(g), section 330(h) and/or section 330(i)* and are requesting funding
in the EMC proposal under section 330(e) to expand services to the
general community or school-aged children and their families (CHC
program), the organization would no longer be eligible to receive a
waiver for the governance requirements and must demonstrate as part of
the application that all of the section 330 governance requirements
have/will be met.

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

CHC applicants, including those previously identified as SBHCs, must
demonstrate compliance with section 330(e) and all applicable BPHC
regulations and guidelines.

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

MHC applicants must 1) address how the special needs of migratory and
seasonal farmworkers and their families are being or will be met, 2)
describe how the EMC proposal will ensure that farmworkers will have
access to comprehensive and preventive health care services through
mechanisms such as: outreach that is integrated into the primary health
care delivery system; use of existing mobile vans or health teams that
travel to migrant camps; transportation; extended clinic hours; etc, 3)
demonstrate how the special environmental health concerns that are
associated with migratory and seasonal farmworkers, will be addressed
and 4) demonstrate compliance with sections 330(e) and 330(g), and all
applicable BPHC regulations and guidelines.

[]{.mark}

In addition, migrant voucher programs applying for EMC funds must
propose to increase new users by the minimum threshold for MHCs as
described in the Definition of Significant Increase in New Users
section. Proposals to expand medical capacity within a migrant voucher
program may only be one of the following: 1) expansion of medical
services provided at fixed delivery sites within the current approved
scope of project; and/or 2) expansion of the number of vouchers offered
to community-based providers. The applicant must assure that the target
population has access to the full range of required services. Voucher
programs must also describe how adjustments will be made for service
delivery during peak and off-season cycles.

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

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 how transportation
and other enabling services will be provided, 3) describe the manner in
which case management, eligibility assistance, and access to housing
services will be made available to homeless patients, and 4) demonstrate
compliance with sections 330(e) and 330(h), and all applicable BPHC
regulations and guidelines.

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

PHPC applicants must demonstrate 1) consultation with the residents in
the development of the application, and 2) compliance with sections
330(e) and 330(i), and all applicable BPHC regulations and guidelines.

### Replacement Sites

Applicants proposing to expand medical capacity by completely replacing
a current site(s) by moving all clinical operations to a larger facility
should do so only if the proposed location for the replacement site(s)
allows the organization to continue to provide access to the same
community/target population within the applicant organization's
currently approved scope of project. **Organizations proposing to
replace a current site(s) must move ALL clinical services from the
site(s) being replaced to the new site and** **must ensure that the new
site(s) will result in a significant increase in new users.** If the
proposed replacement site(s) will not yield a significant increase in
medical users, the proposal will not be eligible under this
announcement. The proposal to replace a site(s) must also address
proximity of the relocated site to other health center delivery sites in
the service area and should assure that providers (including other
section 330 grantees, Federally Qualified Health Center (FQHC)
Look-Alikes, and other primary care providers) serving the same target
population in the same service area have been consulted regarding the
proposed relocation of the site(s). Applicants should include letters or
some other indication of support for the proposed expansion from the
other area providers. Additionally, organizations must indicate the
proposed timeline under which the new facility will be available and
operational. **All replacement sites MUST be operational within 120 days
of receiving an EMC award. (NOTE: On a case by case basis, the BPHC will
consider post-award requests to extend this time limit for good cause.
However, the application should demonstrate assurance that the
replacement site will be operational within 120 days of the award
date.)** EMC funds may not be used to pay for construction costs for a
replacement site.

### Mobile Vans

EMC proposals may include an expansion of the medical capacity of an
**existing** mobile van within the organization's currently approved
scope of project for the delivery of primary care services in any of the
following ways:

-   Renovation or replacement of an existing mobile van currently used
    by the health center (see *section II. Award Information, Maximum
    Grant Support* for restrictions on the amount of the EMC award that
    may be used for one-time minor capital costs);

-   Increase in medical provider FTEs dedicated to the mobile van;

-   Increase in the mobile van's hours of operation; and/or

-   Addition of primary care medical services provided through the
    mobile van.

The existing van must serve one or more locations, operate on a regular,
fixed schedule, and provide primary care services through the use of
clinicians who exercise independent judgment and generate clinical
encounters. **Proposals to add a new** **mobile van would be considered
new access points and would not be eligible for consideration under EMC
funding.**

### Technical Assistance

Applicants are strongly encouraged to work with their respective Primary
Care Association and/or National Associations during the planning and
development of the EMC application. A listing of all Primary Care
Associations can be found on the HRSA website at the following location:
http://bphc.hrsa.gov/OSNP/PCADirectory.htm. See section VIII. Other
Information of this guidance for a list of National Organization
Contacts.

# II. Award Information

## Type of Award

Funding will be provided in the form of a grant.

## Summary of Funding

President Bush's FY 2006 budget proposes an increase of approximately
\$303 million in the appropriation for the Consolidated Health Center
Program authorized under section 330 of the PHS Act. Although
Congressional action on the FY 2006 appropriation has not been
completed, the BPHC anticipates that approximately \$112 million will be
available to support an estimated 303 EMC awards in FY 2006. Final
funding available to support EMC awards and the actual number of awards
to be made may be adjusted after the appropriation is finalized.

This announcement is inviting applications for project periods up to two
(2) years. Awards, on a competitive basis, will be for a one year budget
period, although project periods may be for two (2) years. Awards will
be aligned with the applicant's current approved project period.
Applications for continuation grants funded under these awards beyond
the initial one-year budget period but within the approved project
period will be entertained in subsequent years on a noncompetitive
basis, subject to availability of funds, satisfactory progress of the
grantee and a determination that continued funding would be in the best
interest of the Government.

## Maximum Grant Support

The BPHC has established an annual **cap of \$600,000 for section 330
support** of EMC grants. The cap is the **maximum amount of section 330
funding** that can be requested annually in an EMC grant application in
FY 2006, regardless of the number and/or type of EMC sites to be
supported and/or populations to be served through the application. Not
all applicants approved and funded will receive this maximum amount.
**The total request for section 330 support MUST NOT exceed the
established annual cap of \$600,000 in Year 1 or Year 2. Applications
that present a request for support in excess of the established annual
cap in either Year 1 or Year 2 are considered ineligible for review and
will be returned without further consideration.**

**Applicants may request support up to \$150,000 in Year 1 only for
one-time minor capital costs for equipment and/or
alteration/renovation.** **Total Federal funds requested for the initial
budget period (including the request for one-time funds in Year 1 only)
must be at or below the established EMC cap of \$600,000.** Minor
alteration and renovation 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. No one-time capital
costs should be included in the request for support in the Year 2
operational budget. Any additional minor capital cost necessary to
achieve the goals of the proposal must be covered by other sources.
**Federal funds may not be used to support new construction costs for
activities proposed under this announcement.**

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, etc.) of individuals to be
served. Requests for Federal funding and the proposed budgets must be
aligned with the required minimum increase in the number of new users.
The budget should also be consistent with the service delivery plan and
business plan 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.

Funds can be used to either hire directly or contract with medical
providers. A portion of the funds may be used to: (1) hire outreach
workers and other enabling services staff to increase penetration in
support of the capacity expansion; (2) hire administrative, nursing, and
other support staff (e.g., translators, data analysts, etc.) necessary
to support services provided through this expansion and achieve the
goals and objectives of the proposal; and (3) support one-time minor
capital costs in Year 1 only (up to \$150,000) for renovating and
expanding existing sites or replacing and expanding existing sites to a
location proximate to the current health center(s).

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, revenue generation, and budget/cost
factors. Funding beyond first year is dependent on the availability of
funds, satisfactory performance, and a determination that continuation
of this project is in the best interest of the Federal government.

# III. Eligibility Information

## 

## 1. Eligible Applicants

Organizations eligible to compete include public or nonprofit private
entities, including tribal, faith-based and community-based
organizations.

An application will be considered eligible if it meets all of the
specific eligibility requirements. **Applications that do not meet all
of the following eligibility requirements will not be accepted and will
be returned without further consideration.** Those eligibility
requirements are:

1.  Applicant must be an existing health center grantee. Health center
    grantees are those organizations which currently receive funding
    under the Consolidated Health Center Program authorized under
    section 330 of the Public Health Service (PHS) Act, specifically:

-   Community Health Centers (CHC)[^2] -- 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)

> Note: For the purposes of this guidance, the term "health center"
> refers to CHCs (including previously identified SBHCs), MHCs, HCHs,
> and PHPCs;

2.  Application must propose a significant increase in new users, per
    the Definition of Significant Increase in New Users section on page
    6 of this guidance;

3.  Applicant must submit a request for annual Federal section 330
    funding in Year 1 and Year 2, as presented in Budget Form SF 424A
    and Form 1-B (with accompanying Budget Justification), that **DOES
    NOT exceed the established cap of \$600,000 per year** (including
    one-time capital improvement requests in the Year 1 budget);

4.  Application must adhere to the **80-page limit** on the length of
    the total application when printed by HRSA (including the narrative
    proposal, budget presentation, all other forms, documents,
    appendices, and attachments), whether submitting electronically or
    on paper;

5.  Application must not propose to expand the medical capacity at a
    site that received New Access Point funding in FY 2005 or FY 2006,
    or a site that received EMC funding in FY 2005;

6.  Applicant must not propose to expand capacity to serve a new
    community through the establishment of one or more **NEW** primary
    health care service delivery sites. All sites proposed as EMC sites
    **MUST** be within the applicant's current approved scope of project
    at the time of application or a replacement site of an existing
    site. **Form 3 of the application must reflect the organization's
    most recently approved Form 5-Part B/Exhibit B from a service area
    competition, change in scope, or non-competing continuation
    application as evidence;**

7\. Applicant must not propose to expand capacity for oral health,
mental health, and/or substance abuse services ***only***; and

8.  Applicant organization must not have experienced an overall decline
    in either their user **OR** encounter base, as reported in the UDS
    from CY 2002 to CY 2004, unless a reasonable justification is
    provided that includes a strong, persuasive explanation as to why
    previous downward trends occurred and have since been corrected.
    Otherwise, these levels must be at least at the same level as the
    average of UDS CY 2002 and CY 2003 figures for users and encounters.
    Total organization user and encounter data **as reported in the UDS
    reports for 2002, 2003 and 2004, and any other relevant
    justification** will be used to determine eligibility.

> The table format below is included in the FORM 1-A, General
> Information Worksheet (see page [39](#form-1-part-a)). Total
> organization user and encounter totals **as reported in the UDS
> reports for 2002, 2003 and 2004** must be used to calculate the change
> over this period. The average of UDS 2002 and 2003 should be
> subtracted from UDS 2004 figures. *Applicants that have experienced a
> decrease in users and/or encounters as reported must attach to the
> FORM 1-PART A: General Information Worksheet a strong justification
> for the decrease.* This information will be taken into consideration
> in determining eligibility to participate in the EMC program.

+-------------+---------+----------+---------+----------+-----------+
|             | UDS     | UDS 2003 | UDS     | Average  | Change    |
|             | 2004    |          | 2002    |          |           |
|             |         | \(b\)    |         | '02-'03  | (a)-(d)   |
|             | \(a\)   |          | \(c\)   |          |           |
|             |         |          |         | (        |           |
|             |         |          |         | b)+(c)/2 |           |
|             |         |          |         |          |           |
|             |         |          |         | \(d\)    |           |
+-------------+---------+----------+---------+----------+-----------+
| Total Users |         |          |         |          |           |
+-------------+---------+----------+---------+----------+-----------+
| Total       |         |          |         |          |           |
| Encounters  |         |          |         |          |           |
+-------------+---------+----------+---------+----------+-----------+

## 2. Cost Sharing/Matching

Cost sharing or matching is not a requirement for this funding
opportunity. As required by 42 CFR 51c.305, BPHC 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
for clarification and guidelines pertaining to the presentation of the
budget.

## 3. Other 

## 

Multiple Funded Section 330 Applicant Organizations

Organizations that currently receive support for more than one type of
health center under section 330 may submit only one EMC application.
These organizations may apply for funding to support the expansion of
medical capacity to serve a single population or multiple populations
(for example, homeless individuals only (HCH), or homeless individuals
and other community users (HCH/CHC)). Organizations that receive grants
under multiple section 330 programs are expected to:

-   **Submit only ONE application for the overall organization** (e.g.,
    an organization that receives funding for both CHC and PHPC programs
    may **NOT** submit separate CHC and PHPC proposals).

-   **Request no more than \$600,000 in annualized grant support for
    proposed EMC activities for the organization.**

-   If applying for funding to increase capacity to serve a recognized
    special population, discuss how expanded medical capacity will
    increase access for that targeted population served (e.g.,
    migrant/seasonal farmworkers, homeless individuals, residents of
    public housing, etc.). Multiple funded organizations do not have to
    expand medical capacity for the entire service area, or for all
    special populations served, but may choose to target expansion to a
    particular special population group.

# IV. Application and Submission Information

## 1. Address to Request an Application Package

### Application Materials

The entire application guidance should be reviewed thoroughly prior to
making a decision to apply. **Applicants must submit proposals using
this guidance in conjunction with Public Health Service (PHS)
Application Form 5161-1.** The PHS 5161-1 forms contain additional
general information and instructions for grant applications, proposal
narratives, and budgets; therefore, that information is not repeated in
this document.

The PHS 5161-1 may be downloaded from
<http://www.hrsa.gov/grants/forms.htm>. Instructions for preparing
portions of the application that must accompany PHS Form 5161-1 appear
below.

To request a hard copy of an application kit for this program, please
contact the HRSA Grants Application Center at the following address
(reference Program Announcement Number HRSA 06-054):

The Legin Group, Inc.

HRSA Grant Application Center

Program Announcement Number: HRSA 06-054

901 Russell Avenue, Suite 450

Gaithersburg, MD 20879

Telephone: 877-477-2123

<HRSAGAC@hrsa.gov>.

## 2. Content and Form of Application Submission

### Application Format Requirements

Applications should provide all required information in the sequence and
format described in the instructions. Information and data should be
accurate and consistent, 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 BPHC administrators or sent after the
application deadline will not be added to an application.

If applying on paper, **the entire application submitted for
consideration may not exceed 80 pages in length**. This 80-page limit
includes the abstract, project and budget narratives, attachments,
appendices, any letters of commitment and support, and any supplemental
documents and section separators. If applying electronically, the total
application **may not exceed the equivalent of 80 pages in length when
printed by HRSA, approximately 10 MB**. Pages must be numbered
consecutively. (Note: To ensure that your electronically submitted
application complies with the 80-page limit, it is strongly suggested
that you print out the entire application after entering/uploading into
the on-line system prior to submission.)

**Any EMC application, whether submitted on paper or electronically,
that exceeds the specified limits (80 pages or approximately 10 MB, or
that exceed 80 pages when printed by HRSA) will be deemed non-compliant.
All non-compliant applications will be returned to the applicant without
further consideration.**

*a. Number of Copies (Paper Applications only)*

> Please submit one (1) original and two (2) unbound copies of the
> application. Please do not bind or staple the application. Application
> must be single-sided.
>
> Do not use photo reduction. Do not send photos or over‑sized
> documents, posters, videotapes, cassette tapes or other materials that
> cannot be photocopied. Applicants are cautioned against using color
> prints or graphics. HRSA must make additional copies of an application
> for review purposes; any color print or graphics may not duplicate
> successfully. Computer-generated facsimiles may be substituted for any
> of the forms provided in this packet. Such substitute forms should be
> printed in black ink, but must maintain the exact wording and format
> of the government-printed forms contained in the PHS 5161-1, including
> all captions and spacing. *Deviations may be grounds for the HRSA/BPHC
> to reject the entire application.*

*b. Font*

> Please use an easily readable serif typeface, such as Times Roman,
> Courier, or CG Times. The text 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.

[]{.mark}

*c. Paper Size and Margins*

> For scanning purposes, please submit the application 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.

*d. Numbering*

> Please number the pages of the application sequentially from page 1
> (face page) to the end of the application, including charts, figures,
> tables, and appendices.

*e. Names*

> Please include the name of the applicant on each page.

*f. Section Headings*

Please put all section headings flush left in bold type.

Failure to include all of the documents listed below as part of the
application may result in an application being returned to the applicant
as "incomplete" and will not be considered further. Applications are
limited to **no more than 80 pages in total** including all required and
optional documents, whether submitted on paper or electronically.

### Application Format

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

> i\. Application Face Page
>
> ii\. Table of Contents
>
> iii\. Application Checklist
>
> iv\. Budget

-   SF 424A: Budget Information -- Non-Construction Programs

-   Form 1-B: BPHC Funding Request Summary

> v\. Budget Justification (line item budget plus attached narrative)
>
> vi\. Staffing Plan and Personnel Requirements
>
> vii\. Assurances
>
> viii\. Certifications
>
> ix\. Project Abstract
>
> x\. Program Narrative

-   Service Delivery Plan

-   Business Plan

> xi\. Program-Specific Forms

-   Form 1--A: General Information Worksheet

-   Form 2: Income Analysis Sheet

-   Form 3: EMC Site Table

> xii\. Appendices

-   Appendix A: Job Descriptions for Key Personnel/Positions

-   Appendix B: Biographical Sketches of Key Personnel

-   Appendix C: Organizational Chart

-   Appendix D: Letters of Agreement and/or Contracts

-   Appendix E: Other Relevant Documents

**i. *Application Face Page ***

> Use Public Health Service (PHS) Application Form 5161-1 provided with
> the application package. Prepare this page according to instructions
> provided in the form itself. Please include the title "Expanded
> Medical Capacity, HRSA-06-054." **The Catalog of Federal Domestic
> Assistance Number is 93.224.**
>
> **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/preview/dunsccr.htm> or call
> 1-866-705-5711. Please include DUNS number next to OMB Approval Number
> on the application face page. Applications ***will not*** be reviewed
> without a DUNS number.
>
> Additionally, the applicant organization will be 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/preview/dunsccr.htm>.

ii\. *Table of Contents*

> Provide a Table of Contents for the remainder of the application
> (including appendices), with page numbers.

iii\. *Application Checklist*

> Use Application Form 5161-1 provided with the application package.

iv\. *Budget*

> This announcement is inviting applications for supplemental funding.
> Applicants must submit two 12-month budgets for the proposed project.
> Awards will be aligned with the applicant's current project period.
> Subsequent funding will be based on Congressional appropriations,
> satisfactory progress of the grantee and a determination that
> continued funding would be in the best interest of the Government. The
> Budget section includes the following:
>
> 1\. SF-424A
>
> Use Application Form 5161-1 provided with the application package.
> *Please complete Sections A, B, E, and F.*
>
> 2\. BPHC Funding Request Summary -- FORM 1-B
>
> To facilitate identification of the amount of Federal funding being
> requested, each applicant must complete the FORM 1-B, BPHC Funding
> Request Summary (see page
> [40](#form-1---part-b-bphc-funding-request-summary-fy-2006-emc)).

v\. *Budget Justification*

> The required format for the line-item budget is provided in Attachment
> 2 on page [47](#line-item-budget-justification-required-format) of
> this document.
>
> Provide a line-item budget plus attached narrative that details and
> explains the amounts requested for each line in the PHS Form 5161-1:
> Form SF 424A. Applicants must submit two detailed, 12-month line-item
> budgets that reflect the total revenues and necessary costs for the
> proposed project. (NOTE: Two proposed 12-month operating budgets are
> required regardless of the number of months remaining in the project
> period of the parent grant. If funded, the project period requested
> under this supplemental application will be aligned with the parent
> grant's approved project period). Applicants should also include the
> total organizational budget in the line-item budget.
>
> Each EMC application must include appropriate revenue and expense
> budget justifications for two 12-month operating periods that
> realistically represent resources needed to carry out the goals and
> objectives of the expansion and is reasonable in terms of dollars per
> medical user and the scope of services proposed. (The following is
> provided as a guideline in developing your Federal budget:
> approximately \$150 per medical user for CHC programs, \$200 per
> medical user for MHC programs, \$200 per medical user for HCH
> programs, and \$200 per medical user for PHPC programs. Applications
> that propose a higher Federal grant cost per user must provide an
> adequate justification). In all cases, the proposal must address how
> the revenue projections were made. The projected patient income for
> each 12-month period should be reasonable and based on the patient mix
> and number of projected new users (at least the minimum number of new
> users required). It is understood that the operating budgets of health
> centers are comprised of many revenue streams, some of which can be
> time-limited. The requested level of grant funds (including the
> request for one-time funds) must not exceed the cap of \$600,000
> established for this opportunity. No one-time capital costs should be
> requested in the proposed second or subsequent 12-month operating
> budget(s). The budget requests must reflect the EMC proposal at full
> capacity.
>
> The detailed line-item budget must reflect and expand on the costs
> entered in the PHS Form 5161-1: Form SF 424A. **The additional
> attached budget narrative should specifically describe how each item
> contributes to meeting the project's objectives/goals.** The budget
> narrative must clearly describe each cost element and explain any
> changes from year to year. Be very careful about showing how each item
> in the "other" category is justified. The budget narrative MUST be
> concise. Do NOT use the budget narrative to expand the project
> narrative.
>
> This announcement is inviting applications for project periods up to
> two (2) years. Awards, on a competitive basis, will be for a one year
> budget period, although project periods may be for two (2) years.
> Awards will be aligned with the applicant's current approved project
> period. Applications for continuation grants funded under these awards
> beyond the initial one-year budget period but within the approved
> project period will be entertained in subsequent years on a
> noncompetitive basis, subject to availability of funds, satisfactory
> progress of the grantee and a determination that continued funding
> would be in the best interest of the Government.
>
> Include the following in the Budget Justification line item and/or
> narrative. **The required format for the line item budget
> justification is included in the *Program Specific Forms* section,
> page [47](#line-item-budget-justification-required-format) of this
> guidance.**
>
> *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 the
> exact amount requested for each project year.
>
> *Fringe Benefits:* List the components that comprise the fringe
> benefit rate, for example health insurance, taxes, unemployment
> insurance, life insurance, retirement plan, tuition reimbursement. The
> fringe benefits should be directly proportional to that portion of
> personnel costs that are allocated for the project.
>
> *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 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 for EMC funding are limited to using no
> more than \$150,000 of the total Federal funds requested (not to
> exceed \$600,000 in any year) to support equipment and minor facility
> alteration/renovation in the first year only.*
>
> *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.
>
> *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.
>
> *Alteration and Renovation:* 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 and explanation of each cost in this
> category. In some cases, grantee rent, utilities and insurance fall
> under this category if they are not included in an approved indirect
> cost rate.
>
> *Indirect Costs:* Indirect costs are those costs incurred for common
> or joint objectives which cannot be readily identified but are
> necessary to the operations of the organization, e.g., the cost of
> operating and maintaining facilities, depreciation, and administrative
> salaries. For institutions subject to OMB Circular A-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 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. Position descriptions that include the roles,
> responsibilities, and qualifications of proposed project staff must be
> included in your **Appendix A.** Copies of biographical sketches for
> any key employed personnel that will be assigned to work on the
> proposed project must be included in your **Appendix B.**

vii\. *Assurances*

> Sign and submit all pages of Assurances from Application Form 5161-1
> provided with the application package.

viii\. *Certifications*

> Sign and submit all pages of Certifications from Application Form
> 5161-1 provided with the application package.

ix\. *Project Abstract*

> The project abstract should be single-spaced, limited to one page in
> length, and provide a brief summary of the application. Because the
> abstract may be distributed to the Department of Health and Human
> Services (HHS) and Congress or used in press releases, 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. Please prepare
> the abstract so that it is clear, accurate, concise, and *without
> reference to other parts of the application*.
>
> Please place the following at the top of the abstract:

-   Project title (include "Expanded Medical Capacity, HRSA-06-054" in
    title)

-   Applicant Name

-   Address

-   Contact Phone Numbers (Voice, Fax)

-   E-Mail Address

-   Web Site Address, if applicable

-   Types of section 330 funding requested (i.e., CHC, MHC, HCH, PHPC)

-   Current Federal funding received (including type of section 330
    funds)

x\. *Program Narrative*

> The Program Narrative should provide a comprehensive framework and
> description of all aspects of the proposed EMC project. It should be
> succinct, self-explanatory and well organized so that reviewers can
> understand your proposed project.
>
> **The Program Narrative is expected to describe the EMC site(s) at
> full operational capacity and demonstrate how this will be achieved
> over the first two years of the project.**
>
> All applicants should ensure that each category is completely
> addressed based on the specific elements in the respective Review
> Criterion. Use the following section headers for the Program
> Narrative:

-   **INTRODUCTION (0 points)**

> The introduction is intended to be a brief synopsis of the
> community/target population(s), the applicant organization, and the
> scope of the proposed EMC project.

-   **NEED (20 points maximum)**

> See Criterion 1: NEED in the Review Criteria section (page
> [27](#_Ref84836858)) for the specific elements that should be
> addressed.

-   **RESPONSE (35 points maximum)**

> See Criterion 2: RESPONSE in the Review Criteria section (page
> [29](#_Ref84836847)) for the specific elements that should be
> addressed.
>
> Present a detailed description of the proposed EMC project, including
> the number and location of sites targeted, the types of services
> targeted, and the extent to which the primary health care services
> will be increased at each site. Describe how the proposed project is
> responsive to the access barriers identified in the previous NEED
> Section.
>
> Include a **Service Delivery Plan** that outlines specific
> goals/objectives, action items, and desired outcomes for the EMC
> project. Address how the proposed EMC service delivery plan relates to
> the Health Care Plan for the entire organization. Also address
> proposed changes or increases in levels of effort that are necessary
> to support the EMC project.
>
> Include a **Business Plan** that outlines specific goals/objectives,
> action items, and desired outcomes for the EMC project. The plan
> should address the systems of the health center (e.g., Administrative,
> Fiscal, Clinical, MIS, Governance, etc.), and the proposed changes or
> increases in levels of effort that are necessary to support the
> proposed EMC project. (See page
> [49](#attachment-3-service-delivery-plan-and-business-plan) for
> required format for Service Delivery and Business Plans.)

-   **EVALUATIVE MEASURES (10 points maximum)**

> See Criterion 3: EVALUATIVE MEASURES in the Review Criteria section
> (page [30](#_Ref84836880)) for the specific elements that should be
> addressed.

-   **IMPACT (5 points maximum)**

> See Criterion 4: IMPACT in the Review Criteria section (page
> [30](#_Ref84836892)) for the specific elements that should be
> addressed.

-   **RESOURCES/CAPABILITIES (20 points maximum)**

> See Criterion 5: RESOURCES/CAPABILITIES in the Review Criteria section
> (page [30](#_Ref84836902)) for the specific elements that should be
> addressed.

-   **SUPPORT REQUESTED (10 points maximum)**

> See Criterion 6: SUPPORT REQUESTED in the Review Criteria section
> (page [31](#_Ref84836916)) for the specific elements that should be
> addressed.

xi\. *Program-Specific Forms*

> Please refer to Attachment 1 (see page
> [38](#attachment-1-program-specific-forms)) for copies of all program
> specific forms. This section provides Forms to present other required
> program-specific information. Please complete and place in the
> Program-Specific forms section of the application unless otherwise
> noted below.
>
> All applicants must complete the following:

-   **FORM 1--A: General Information Worksheet:** see page
    [39](#form-1-part-a). This form should present summary information
    that is consistent with the budget, user and encounter projections
    presented in the project description, Service Delivery and Business
    Plans and any other forms.

-   **FORM 2: Income Analysis Format:** see page [41](#_Ref84847978).
    Complete an Income Analysis (2 pages) for Year 1 and Year 2.
    Indicate projections for patient service revenue for each year by
    breaking out revenue by payment source.

-   **FORM 3: EMC Site Table:** see page
    [45](#form-3-fy-2006-emc-service-site-table). Applicants should
    include addresses **for only those sites to be expanded** as part of
    the EMC application, including any proposed replacement sites.

xii\. *Appendices*

> Please provide the following items to complete the content of the
> application. Be sure each appendix is clearly labeled.
>
> **Appendix A: Job Descriptions for Key Personnel/Positions**
>
> Keep each to one page in length as much as possible. Item 6 in the
> Program Narrative section of the PHS 5161-1 Form provides some
> guidance on items to include in a job description.
>
> **Appendix B: Biographical Sketches of Key Personnel**
>
> Include biographical sketches for persons occupying the key positions
> described in the narrative, not to exceed one page in length. 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.
>
> **Appendix C: Organizational Chart**
>
> Provide a one-page figure that depicts the project within the
> organizational structure, including any subcontractors and other
> significant collaborators.
>
> **Appendix D: Letters of Agreement and/or Description(s) of
> Proposed/Existing Contracts**
>
> Provide any project specific documents that describe working
> relationships between the applicant agency and other agencies and
> programs cited in the proposal. Documents that confirm actual or
> pending contractual agreements should clearly describe the roles of
> the subcontractors and any deliverables. Letters of agreements must be
> dated.
>
> **Appendix E: Other Relevant Documents**
>
> Include here any other documents that are relevant to the application,
> including tables, charts, map of the service area, and letters of
> support. Letters of support must be dated. Include only letters of
> support which specifically indicate a commitment to the
> project/program (in-kind services, dollars, staff, space, equipment,
> etc.) List all other support letters on one page.

## 3. Submission Dates and Times

Application Due Date

The due date for applications under this grant announcement is December
15, 2005 at 5:00 P.M. ET.

**It is the responsibility of the applicant to ensure that the complete
application is submitted electronically or postmarked by the published
due date.** Applications will be considered received on time if received
or postmarked by the due date, as shown only by the electronic
submission record or a legible U.S. Postal Service dated postmark or a
legible date receipt from a commercial carrier. **Applications submitted
electronically or postmarked after the due date will not be accepted for
processing and will be returned without consideration.**

Applications will be considered as meeting the deadline if they are
either:

\(1\) Received on or before the due date; or

\(2\) Postmarked or E marked on or before the due date, and received in
time for the Independent Review Committee review.

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 nature (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).

Electronic Submission

Applications must be submitted by 5:00 P.M. ET. **To ensure that you
have adequate time to follow procedures and successfully submit the
application, we recommend you start submission no later than noon on the
due date.** Applications submitted electronically will be time/date
stamped electronically, which will serve as receipt of submission.

Paper Submission

Upon receipt of a paper application, the Grants Application Center will
mail an acknowledgement of receipt to the applicant organization's
Program Director.

In the event that questions arise about meeting the application due
date, applicants must have a legibly dated receipt from a commercial
carrier or the U.S. Postal Service. Private metered postmarks will not
be accepted as proof of timely mailing.

Late Applications

Applications that 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

This funding opportunity is subject to the provisions of Executive Order
12372, as implemented by 45 CFR 100. Executive Order 12372 allows States
the option of setting up a system for reviewing applications from within
their States for assistance under certain Federal programs. Application
packages made available under this guidance will contain a listing of
States that have chosen to set up such a review system, and will provide
a State Single Point of Contact (SPOC) for the review. Information on
states affected by this program and State Points of Contact may also be
obtained from the Grants Management Officer listed in the Agency
Contacts section, as well as from the following Web site:
<http://www.whitehouse.gov/omb/grants/spoc.html>.

All applicants other than federally recognized Native American Tribal
Groups should contact their SPOC as early as possible to alert them to
the prospective applications and receive any necessary instructions on
the State process used under this Executive Order.

Letters from the SPOC in response to Executive Order 12372 are due sixty
days after the application due date.

State Coordination

It is suggested that all applicants should contact their State Primary
Care Associations (PCAs), State Primary Care Offices (PCOs) to alert
them to the prospective applications and if applicable, coordinate
application with State primary care activities. Listings of PCAs and
PCOs can be found at the following websites:

> PCAs: <http://bphc.hrsa.gov/OSNP/PCADirectory.htm>

PCOs: <http://bphc.hrsa.gov/OSNP/PCODirectory.htm>

## 5. Funding Restrictions 

Awards to support projects beyond the first budget year will be
contingent upon Congressional appropriation, satisfactory progress in
meeting the project's objectives, and a determination that continued
funding would be in the best interest of the government.

Applicants responding to this announcement may not request funding
greater than the allowable cap of \$600,000 per year in Federal funds
for EMC applications.

Consistent with the statutory restrictions, section 330 funds may not be
used for construction of facilities. Funds may, however, be used for
minor capital cost including equipment and minor alteration and
renovation. Applicants may request to use up to \$150,000 of Federal
funds in the first year of the EMC project for such minor capital costs;
however, the total Federal section 330 funds requested may not exceed
the established cap of \$600,000 in any year.

## 6. Other Submission Requirements

### Electronic Submission

You may submit your application either in electronic or paper format. To
submit an application electronically, please use the
[http://www.Grants.gov](http://www.Grants.gov/) apply site. If you use
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 e-mail an electronic
copy of a grant application to us.

Please note the following if you plan to submit your application
electronically via Grants.Gov:

> • Electronic submission is voluntary
>
> • When you enter the Grants.Gov site, you will find information about
> submitting an application electronically through the site, as well as
> the hours of operation. We strongly recommend that you do not wait
> until the application deadline date to begin the application process
> through Grants.Gov. The registration process is a separate process
> from submitting an application. **Applicants are, therefore,
> encouraged to register early**. The registration process can take
> approximately two weeks to be completed. Therefore, registration
> should be done in sufficient time to ensure it does not impact your
> ability to meet required submission deadlines. You will be able to
> submit your application online anytime after you receive your
> e-authentication credentials.
>
> • To use Grants.gov, you, as the applicant, must have a DUNS Number
> and register in the Central Contractor Registry (CCR). You should
> allow a minimum of five days to complete the CCR registration.
>
> • You will not receive additional point value because you submit a
> grant application in paper format.
>
> • You may 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. The Health Resources and Services
> Administration will retrieve your application from Grants.Gov.
>
> • You may access the electronic application for this program on
> [http://www.Grants.gov](http://www.Grants.gov/).
>
> • You must search for the downloadable application package by the CFDA
> number.
>
> • 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**](mailto: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.

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. 

**Formal submission of the electronic application:** Applications
completed online are considered formally submitted when the Authorizing
Official electronically submits the application to HRSA. 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 can be printed from the online
application.

>  

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

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 the deadline date.

REMINDER: Only applicants who apply online are permitted to forego
hard-copy submission of all application forms EXCEPT the signed
SF-424/5161.

>  

If the application is submitted as a hard-copy, the rules of submission
as described elsewhere in this guidance must be followed.

### Paper Submission

If you choose to submit paper copy, please send the original and two (2)
copies of the application to:

> The HRSA Grants Application Center
>
> The Legin Group, Inc.
>
> Attn: *Expanded Medical Capacity*
>
> Program Announcement No. *HRSA-06-054*
>
> CFDA No. *93.224*
>
> 901 Russell Avenue, Suite 450
>
> Gaithersburg, MD 20879
>
> Telephone: 877-477-2123

In the event that questions arise about meeting the application due
date, applicants must have a legibly dated receipt from a commercial
carrier or the U.S. Postal Service. Private metered postmarks will not
be accepted as proof of timely mailing.

Whether you submit electronically or via paper, 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, whether electronically or on paper.

# V. Application Review Information

## 

## 1. Review Criteria

Procedures for assessing the technical merit of grant applications have
been instituted to provide for an objective review of applications and
to assist the applicant in understanding the standards against which
each application will be judged. Critical indicators have been developed
for each review criterion to assist the applicant in presenting
pertinent information related to that criterion and to provide the
reviewer with a standard for evaluation.

All EMC applicants should ensure the following six (6) Review Criteria
are fully addressed within the Program Narrative and supported by other
supplementary information in the other sections of the application, as
appropriate. The following Review Criteria will be used by the Objective
Review Committee (ORC) to evaluate the merits of the proposed plan
presented in each EMC application.

Reviewers will assign points based on how well the application has
addressed each of the Review Criteria. The six (6) Review Criteria for
the EMC funding opportunity and maximum points awarded are as follows:

> []{#_Ref84836858 .anchor}CRITERION 1: NEED (20 points maximum)

1.  Applicant clearly describes the service area(s)/community(ies) to be
    impacted by the EMC project, including:

    a.  The service area population and the area to be served (i.e.,
        urban, rural).

    b.  If the applicant is requesting a funding preference as a
        sparsely populated rural frontier area (i.e., the *entire
        proposed service area* has 7 or fewer people per square mile).
        *Note: The request must also be specified by checking the
        appropriate box on FORM 1-PART A: General Information Worksheet,
        and provide documentation (i.e., current census data) to support
        the request.*

    c.  The counties, census tracts, minor civil divisions,
        schools/school districts, etc., (as appropriate) in the service
        area.

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

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1.  Applicant clearly describes the target population(s) for the EMC
    project including:

> \(a\) The unserved and underserved populations in the community,
> including migrant/seasonal farmworkers (MSFWs), homeless people,
> public housing residents, and any other populations in need of access
> to primary health care (e.g., low-income school children/adolescents
> and their families, elderly people, recent immigrants).
>
> \(b\) The unique demographic characteristics of the target population
> (e.g., age, gender, insurance status, unemployment, poverty level,
> ethnicity/culture, education, etc.).
>
> \(c\) The relevant access to care and health status indicators of the
> target population/community including the most common causes of
> mortality and the incidence and prevalence of chronic and infectious
> diseases.

2.  Applicant clearly 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
    addressed by the EMC project. This should include a description of:

> \(a\) Any culturally specific characteristics that impact access to
> and the delivery of health care services.
>
> \(b\) Any relevant geographic barriers to care and other factors
> impacting access to care.
>
> \(c\) Any major and/or unique health care needs of the target
> population(s).

3.  For those organizations proposing to serve a new population (i.e.,
    MSFWs, homeless people, public housing residents) for which they do
    not currently receive Federal support, the applicant clearly
    identifies the specific health care needs and barriers to care for
    this population to be addressed by the EMC project and justifies the
    need to expand its focus to new populations.

4.  Applicant clearly describes any significant changes over the past
    year in the health care environment, service area or population
    being served (e.g., influx of refugee population, closing of local
    factory) impacting on the need for services. This should include a
    description of any significant changes for each target population
    type served (i.e., MSFWs, homeless people, public housing residents,
    low-income school children/adolescents and their families).

5.  Applicant clearly identifies any health care providers (including
    all other FQHC Look Alikes and section 330 grantees), resources
    and/or services of other public and private organizations within the
    proposed service area that are providing care to the target
    population(s). Appropriate justification is provided as to why
    existing health center resources and other local resources (e.g.,
    other HRSA supported programs, rural health clinics, etc.) are
    unable to meet the need for increased access to primary care.

> []{#_Ref84836847 .anchor}CRITERION 2: RESPONSE (35 points maximum)

1.  Applicant provides a detailed description of the proposed project
    that is appropriate and responsive to the identified community and
    target population health care needs. Included should be the number
    and location of targeted EMC sites, the number of new patients to be
    served, the number of new encounters projected, the types of
    services impacted, the increase in providers and support staff, and
    any increase or modification to hours of operation. Applicant must
    include the number of users and encounters for each special
    population, (i.e., MSFWs, homeless, public housing residents) if
    funds are requested for one or more of these populations.

2.  Applicant describes reasonable and appropriate strategies/methods
    that will attract new users, expand access to primary care services
    for the target population and increase primary care medical
    capacity. Strategies may include but are not limited to providing
    additional services, additional providers where excess facility
    capacity exists, expanded hours of operation, or providing
    additional services through contractual relationships (e.g., OB/GYN)
    at existing sites. If the proposal includes completely relocating an
    existing site(s) to a more appropriate facility, the applicant
    clearly demonstrates how the project will continue to maximize
    access to health care for the community currently being served by
    the existing site.

3.  Applicant provides a Service Delivery Plan that is appropriate and
    realistic for the proposed EMC project, and responsive to the
    identified needs of the community, including any targeted health
    disparities. The plan includes adequate medical and other providers
    (e.g., outreach workers, case managers) and support staff associated
    with the expansion. The Service Delivery Plan addresses its impact
    on the current Heath Care Plan for the organization, and any
    significant changes (e.g., serving a new population or age group, or
    expanding into new services) are noted in an addendum to the
    existing Health Care Plan. (See page
    [49](#attachment-3-service-delivery-plan-and-business-plan) for
    required format for Service Delivery Plan.)

4.  Applicant provides a Business Plan that is appropriate and realistic
    for the proposed EMC project. Each relevant component of the Heath
    Center (e.g., Administration, Fiscal, Clinical, MIS, Governance,
    etc.) is sufficiently addressed, and the goals and activities are
    appropriate for the proposed project. (See page
    [49](#attachment-3-service-delivery-plan-and-business-plan) for
    required format for Business Plan.)

5.  Applicant proposes appropriate plans for incorporating or improving
    the use of outreach and other enabling services to bring new users
    in to the health centers and/or medical services, both for
    traditional health center users and, where applicable, for special
    populations (e.g., MSFWs, homeless individuals and families,
    residents of public housing).

6.  Applicant demonstrates that the new or expanded services being
    proposed are culturally and linguistically appropriate for the
    populations to be served.

7.  For organizations proposing an expansion to serve a population for
    which they do not currently receive Federal support, the applicant:

> \(a\) Demonstrates awareness of the appropriate organizational changes
> to be made (per statutory and other requirements and expectations of
> health centers). Areas of consideration include representation in
> governance, and modifications to clinical and business systems,
> enabling services and overall cultural competency.
>
> \(b\) Presents a sound plan to assure compliance upon receipt of
> funding.
>
> \(c\) Assures the organization's ability to implement the necessary
> changes.
>
> Note: This includes organizations that currently receive funding to
> serve a special population(s) only (i.e., MHCs, HCHs, PHPCs) and are
> requesting Federal support for an EMC proposal to serve
> traditional/general population users (i.e., CHC).

8.  Applicant provides a feasible and credible timeline for
    implementation of the project. The applicant demonstrates
    operational readiness within 120 days of award (i.e., proposed staff
    recruited and services provided), including those applicants
    proposing to open a replacement site.

> []{#_Ref84836880 .anchor}CRITERION 3: EVALUATIVE MEASURES (10 points
> maximum)

1.  Applicant demonstrates the ability to evaluate the effectiveness of
    the EMC project, including the quality and outcomes of the services
    provided (e.g., adequate management information systems, patient
    satisfaction). Applicant provides an evaluation plan that is
    appropriate for the EMC project goals and projected outcomes.

2.  If applicable, the applicant describes the health center's
    successful progress in meeting the initial goals and objectives
    under a time-limited State funded program (i.e., incubator program),
    and how these goals/objectives will align with the proposed EMC
    project.

3.  Applicant demonstrates an appropriate quality improvement program
    that includes eliminating disparities in health outcomes, reducing
    patient risk, credentialing and privileging, incident reporting,
    etc.

4.  Applicant describes 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).

> []{#_Ref84836892 .anchor}CRITERION 4: IMPACT (5 points maximum)

1.  Applicant demonstrates the extent to which the proposed EMC project
    will increase access to care and eliminate major barriers to care
    for the medically underserved in the community/target population(s)
    to be served.

2.  Applicant demonstrates the extent to which the proposed EMC project
    will address the major health care needs and reduce health
    disparities for the medically underserved in the community/target
    population(s) to be served.

> []{#_Ref84836902 .anchor}CRITERION 5: RESOURCES/CAPABILITIES (20
> points maximum)

1\. Applicant clearly describes its mission and structure, scope of
current activities (including participation in a state-funded incubator
program if applicable) and systems, and includes an organizational chart
depicting the EMC project within the organizational structure in
Appendix C. The applicant also demonstrates the organization's ability
to successfully implement the proposed medical expansion project and
meet program expectations.

2.  Applicant demonstrates experience with similar projects and
    sufficient knowledge, skills and abilities within the organization
    to successfully implement the EMC project. (e.g., previous
    successful expansion projects, etc.)

3.  Applicant demonstrates and documents that it is operating at full
    capacity for the providers currently in place and the resources
    currently available.

4.  Applicant discusses the ability and experience of the proposed
    management team in leading and managing internal administrative,
    human resources, financial systems, information systems, and
    clinical disciplines.

5.  Applicant demonstrates that the facilities proposed for the EMC
    project are adequate and appropriate for the projected increase in
    the provision of services. The applicant also provides an
    appropriate plan for any necessary facility
    modifications/renovations.

> 6\. Applicant demonstrates appropriate collaboration with other area
> providers (including other section 330 funded programs), to minimize
> duplication of services and assure an effective continuum of care.
> MOAs, MOUs, and/or a list of additional letters of commitment, on file
> at the health center, should be included as appropriate in Appendix D.
>
> 7\. Applicant demonstrates and provides evidence of the community's
> support for the proposed EMC project. Letters of support should be
> included as appropriate in Appendix E.
>
> 8\. For applicants proposing to expand into new target populations,
> the applicant demonstrates an awareness of all appropriate
> organizational changes necessary for a successful project, a plan for
> compliance and the ability to implement the necessary organizational
> changes for serving new populations. The applicant must discuss the
> changes necessary to comply with all relevant program requirements to
> receive grant funds for services targeted to the proposed populations.
> The application certifies that the organization will be brought into
> compliance upon receipt of grant funding, and include information
> exhibiting the applicants ability to do so.

9.  Applicant demonstrates that the organization's existing operations
    will not be jeopardized if the expansion budget projections are not
    realized, and that the addition of new providers and staff will not
    adversely affect the efficiency of current providers.

> []{#_Ref84836916 .anchor}CRITERION 6: SUPPORT REQUESTED (10 points
> maximum)

1.  Applicant demonstrates in the budget presentation, two 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 EMC project (i.e., total project budget) and Business
> Plan provided as part of the RESPONSE section of the Program
> Narrative;
>
> \(c\) 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, after the first
> year of finding, and at full capacity after two years of funding;
>
> \(f\) 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.

2.  Applicant demonstrates how all sources of revenue, including
    non-Federal, will be maximized.

3.  Applicant presents a budget narrative that is complete,
    comprehensive and provides an explanation for each budget line item.

4.  Applicant describes how the proposed expansion project 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.

## 2. Review and Selection Process

The HRSA 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 a committee, e.g.,
geographic distribution, race/ethnicity, and gender. 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.

All EMC applications will be reviewed initially for eligibility,
completeness and responsiveness to the program guidance. Applicants are
reminded that applications MUST NOT exceed 80 pages in total, including
all required and optional attachments, whether submitted on paper or
electronically. **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 to the
applicant without further consideration.**

### Funding Preferences 

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 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** proposed service area for the EMC project has seven or
> fewer people per square mile (i.e., all census tracts within the
> defined service area meet the definition). Applicants requesting
> consideration of a funding preference must indicate the request on
> Form 1-A: General Information Worksheet, and attach to it
> documentation indicating that the entire area served has seven or
> fewer people per square mile (e.g., most recent Census Bureau data).

### Other Awarding Factors

HRSA intends to achieve a wide distribution of EMC awards in FY 2006.
HRSA will consider all of the following factors, in addition to the
preference indicated above, in making EMC awards in FY 2006. As well as
those listed below, the need for primary health care services within a
Federally defined county along the United States/Mexico Border has been
identified as an area of high need. Therefore, we strongly encourage all
eligible applicants in these areas to submit an application under this
announcement.

*RURAL/URBAN DISTRIBUTION OF AWARDS*

Aggregate awards in FY 2006 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 2006 to support the various types of health
centers will be made to ensure continued proportionate distribution of
funds across the Consolidated Health Center Program.

*GEOGRAPHIC CONSIDERATION*

The goal of the HRSA in making this funding announcement is to expand
the current safety net on a national basis. Therefore, the HRSA will
consider geographic distribution when deciding which applications to
fund.

*PERFORMANCE UNDER SECTION 330 PROGRAM EXPECTATIONS*

Current grantees found to be out of compliance with section 330 program
expectations may not be considered for funding.

### 

## 3. Anticipated Announcement and Award Date

Funding decisions will be announced on or around **June 1, 2006.**

# VI. Award Administration Information

## 1. Award Notices

Each applicant will receive written notification of the outcome of the
objective review process, including a summary of the objective review
committee's assessment of the application's merits and weaknesses, and
whether the application was selected for funding. Organizations whose
applications are selected for funding may be required to respond in a
satisfactory manner to Conditions placed on their application before
funds can be awarded. Letters of notification of funding do not provide
authorization to begin performance. Successful applicants will receive a
Notice of Grant Award from the Division of Grants Management Operations
following the announcement of the funding decisions. The Notice of Grant
Award, which is signed by the Grants Management Officer and is sent to
the applicant agency's Authorized Representative, is the authorizing
document and will be sent prior to the applicable start date.

## 2. Administrative and National Policy Requirements

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

Public Policy Issuance

**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.

As part of the Service Delivery Plan, applicants must summarize those
programs objectives and/or sub-objectives that relate to the goals of
the Healthy People 2010 initiative.

Copies of the Healthy People 2010 may be obtained from the
Superintendent of Documents or downloaded at the Healthy People 2010
website: <http://www.health.gov/healthypeople/document/>.

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

Instructions for post-award reporting (e.g., frequency, paper or
electronic submission) will be provided in the Notice of Grant Award.
Successful applicants under this guidance must:

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

(b) Submit a Payment Management System Quarterly Report. The reports
    identify cash expenditures against the authorized funds for the
    grant. Failure to submit the report may result in the inability to
    access grant funds. Reports are to be submitted to:

Division of Payment Management

DPM/FMS/PSC/ASAM/HHS

PO Box 6021

Rockville, MD 20852

Telephone: (301) 443-1660

(c) 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;

(d) Submit a Progress Report(s).

# 

## 4. Performance Review

HRSA's Office of Performance Review (OPR) serves as the agency's focal
point for reviewing and enhancing the performance of HRSA funded
programs within communities and States. 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>.

# VII. Agency Contacts

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

> Mike Rowland
>
> HRSA/Division of Grants Management Operations, OFAM
>
> 5600 Fishers Lane, 11A-16
>
> Rockville, MD 20857
>
> Phone: 301-594-4243
>
> Fax: 301-594-4073
>
> Email: <mike.rowland@hrsa.hhs.gov>

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

> Kirsten Argueta
>
> HRSA/Bureau of Primary Health Care
>
> Division of Policy and Development
>
> 5600 Fishers Lane, 17-61
>
> Rockville, MD 20857
>
> Telephone: (301) 594-4300
>
> Fax: (301) 594-4997
>
> Email: <kirsten.argueta@hrsa.hhs.gov>

# 

# VIII. Other Information

# 

### Contact Information for Application Development Assistance

Contact information for Primary Care Associations and Primary Care
Offices can be found at the following website:
<http://bphc.hrsa.gov/osnp/pcapco.htm>

In addition, the following National Organizations may be contacted for
additional assistance in preparing an EMC application:

Karen Mountain

Migrant Clinicians Network, Inc.

P.O. Box 16485

Austin, TX 78716

Tel: 512-327-2017

Email: kmountain@migrantclinician.org

www.migrantclinician.org

Laura Brey

National Assembly on School-Based HealthCare

Center for Technical Assistance and Training

666 11^th^ Street, NW

Washington, DC 20001

Tel: 202-638-5872 ext. 202

Email: lbrey@nasbhc.org

www.nasbhc.org

Pamela J. Byrnes, Ph.D.

National Association of Community Health Centers

Managed Growth Assistance Program

50 South Washington Avenue

Niantic, CT 06357

Tel: 860-739-9224

Fax: 860-691-1388

Email: pbyrnes@nachc.com

www.nachc.com

Alicia Gonzales

National Center on Farmworker Health

1770 FM 967

Buda, TX 78610

Tel: 512-312-5469

Email: Gonzales@ncfh.org

www.ncfh.org

Karen Rotondo

National Health Care for the Homeless Council

13 Railway Bluffs

Hyannis Park, MA 02601

Tel: 508-775-4374

Email: kerotondo@aol.com

www.nhchc.org

# IX. Tips for Writing a Strong Application

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

**Keep your audience in mind.** Reviewers will use only the information
contained in the application to assess the application. Therefore, the
applicant should 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 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 appendices.** Do not use the appendices 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
pages are numbered (including appendices) and that page limits are
followed. Limit the use of abbreviations and acronyms, and define each
one at its first use and periodically throughout the application.

**Print out and carefully review an electronic application.** If
submitting electronically, print out the application before submitting
it to ensure appropriate formatting and adherence to page limit
requirements.

# [Attachment 1:]{.smallcaps} [Program Specific Forms]{.smallcaps}

####### 

## FORM 1-PART A:![](media/image1.wmf){width="1.7479166666666666in" height="0.3326388888888889in"}![](media/image1.wmf){width="1.4604166666666667in" height="0.2902777777777778in"}

## GENERAL INFORMATION WORKSHEET - FY 2006 EMC

Applicant Name: UDS #:

Name of Contact Person: Title:

Mailing/Street Address: City, State, Zip:

Phone: Fax: Email:

**Please Check:** ‪ URBAN RURAL SPARSELY POPULATED/FRONTIER (persons per
square mile:\_\_\_\_\_\_\_)

**[GENERAL INFORMATION]{.underline}:** Total Health Center Service Area
Population:

+---------+------------------+--------------------+-------------------+
|         | **TOTAL Federal  | **TOTAL ONE-TIME** | **TOTAL PROJECT   |
|         | Funding          |                    | BUDGET**          |
|         | Requested**      | **(included in     |                   |
|         |                  | Year 1 Federal     |                   |
|         |                  | Funds Requested)** |                   |
+---------+------------------+--------------------+-------------------+
| **Year  |                  |                    |                   |
| 1**     |                  |                    |                   |
+---------+------------------+--------------------+-------------------+
| **Year  |                  | []{.mark}          | []{.mark}         |
| 2**     |                  |                    |                   |
+---------+------------------+--------------------+-------------------+

+-------------+---------+----------+---------+----------+-----------+
|             | UDS     | UDS 2003 | UDS     | Average  | Chang     |
|             | 2004    |          | 2002    |          | e**\*\*** |
|             |         | \(b\)    |         | '02-'03  |           |
|             | \(a\)   |          | \(c\)   |          | (a)-(d)   |
|             |         |          |         | (        |           |
|             |         |          |         | b)+(c)/2 |           |
|             |         |          |         |          |           |
|             |         |          |         | \(d\)    |           |
+-------------+---------+----------+---------+----------+-----------+
| Total Users |         |          |         |          |           |
+-------------+---------+----------+---------+----------+-----------+
| Total       |         |          |         |          |           |
| Encounters  |         |          |         |          |           |
+-------------+---------+----------+---------+----------+-----------+

+--------------------------------------------------------+------+------+
| FUNDING PREFERENCE                                     | R    |      |
|                                                        | eque |      |
|                                                        | sted |      |
|                                                        |      |      |
|                                                        | Yes  |      |
|                                                        | No   |      |
+--------------------------------------------------------+------+------+
| Sparsely Populated Rural Frontier Areas                |      |      |
|                                                        |      |      |
| **(persons/mile^2^: [)\*]{.underline}**                |      |      |
+--------------------------------------------------------+------+------+

*\*Applicants requesting a funding preference must attach evidence
(i.e., Census data) to this form that the entire proposed service area
meets the definition of sparsely populated (7 or fewer persons/sq.
mi.).*

> *\*\*Any decline in total users OR encounters (i.e., negative change)
> must be explained/justified in an attachment to this form. This
> information will be considered when determining eligibility to compete
> for EMC funding.*

+-----------------------+----------+----------+-----------+-----------+
| TARGET                | \(b\)    | \(c\)    | \(d\)     | \(e\)     |
|                       |          |          |           |           |
| POPULATION            | CURRENT  | NUMBER   | CHANGE IN | PERCENT   |
|                       | NUMBER   | OF USERS | NEW USERS | CHANGE IN |
| (Total Organizational | OF USERS |          | AFTER 2   | NEW USERS |
| Users)                |          | P        | YEARS     | AFTER 2   |
|                       | *(2004   | ROJECTED |           | YEARS     |
|                       | UDS      | AFTER 2  | (c-b)     |           |
|                       | F        |          |           | (         |
|                       | IGURES)* | YEARS    |           | d/b)\*100 |
+-----------------------+----------+----------+-----------+-----------+
| Migrants/Seasonal     |          |          |           |           |
| Farmworkers           |          |          |           |           |
+-----------------------+----------+----------+-----------+-----------+
| Homeless Individuals  |          |          |           |           |
+-----------------------+----------+----------+-----------+-----------+
| Residents of Public   |          |          |           |           |
| Housing               |          |          |           |           |
+-----------------------+----------+----------+-----------+-----------+
| All Other CHC Users   |          |          |           |           |
+-----------------------+----------+----------+-----------+-----------+
| Grand Total Users     |          |          |           |           |
+-----------------------+----------+----------+-----------+-----------+
| Total Users at        |          |          |           |           |
| 100-199% FPL          |          |          |           |           |
+-----------------------+----------+----------+-----------+-----------+
| Total Users below     |          |          |           |           |
| 100% FPL              |          |          |           |           |
+-----------------------+----------+----------+-----------+-----------+
| Total Uninsured Users |          |          |           |           |
+-----------------------+----------+----------+-----------+-----------+
| Total FTE Providers   |          |          |           |           |
+-----------------------+----------+----------+-----------+-----------+

## FORM 1 - PART B: BPHC FUNDING REQUEST SUMMARY -- FY 2006 EMC

> *Instructions: EMC 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 two 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 or Year 2
> MAY NOT exceed the published cap of \$600,000 established for EMC
> applications.*

+-------------+---+---------+----+---+--------+--------+----------------+
| FEDERAL     |   |         |    |   |        |        |                |
| FUNDS       |   |         |    |   |        |        |                |
| REQUESTED   |   |         |    |   |        |        |                |
| BASED ON A  |   |         |    |   |        |        |                |
| 12-MONTH    |   |         |    |   |        |        |                |
| BUDGET FOR  |   |         |    |   |        |        |                |
| YEAR 1 and  |   |         |    |   |        |        |                |
| YEAR 2      |   |         |    |   |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **REQUESTED |   | **PR    | ** |   | **Year |        | **Year 2**     |
| BPHC        |   | OGRAM** | CF |   | 1**    |        |                |
| PROGRAM:    |   |         | DA |   |        |        |                |
| (May        |   |         | ** |   |        |        |                |
| request     |   |         |    |   |        |        |                |
| funding     |   |         |    |   |        |        |                |
| under more  |   |         |    |   |        |        |                |
| than one    |   |         |    |   |        |        |                |
| section 330 |   |         |    |   |        |        |                |
| program)**  |   |         |    |   |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
|             |   |         |    |   | **[Ope | **[    |                |
|             |   |         |    |   | ration | One-ti |                |
|             |   |         |    |   | al]{.m | me]{.m |                |
|             |   |         |    |   | ark}** | ark}** |                |
|             |   |         |    |   |        |        |                |
|             |   |         |    |   |        | **[(up |                |
|             |   |         |    |   |        | to     |                |
|             |   |         |    |   |        | \$     |                |
|             |   |         |    |   |        | 150,00 |                |
|             |   |         |    |   |        | 0)]{.m |                |
|             |   |         |    |   |        | ark}** |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **Community |   | *       | ** |   |        |        |                |
| Health      |   | *330(e) | 93 |   |        |        |                |
| Center**    |   | (CHC)** | .2 |   |        |        |                |
|             |   |         | 24 |   |        |        |                |
|             |   |         | ** |   |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **Migrant   |   | *       | ** |   |        |        |                |
| Health      |   | *330(g) | 93 |   |        |        |                |
| Center**    |   | (MHC)** | .2 |   |        |        |                |
|             |   |         | 24 |   |        |        |                |
|             |   |         | ** |   |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **Health    |   | *       | ** |   |        |        |                |
| Care for    |   | *330(h) | 93 |   |        |        |                |
| the         |   | (HCH)** | .2 |   |        |        |                |
| Homeless**  |   |         | 24 |   |        |        |                |
|             |   |         | ** |   |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **Public    |   | *       | ** |   |        |        |                |
| Housing     |   | *330(i) | 93 |   |        |        |                |
| Primary     |   | (       | .2 |   |        |        |                |
| Care**      |   | PHPC)** | 24 |   |        |        |                |
|             |   |         | ** |   |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **TOTAL     |   |         |    |   |        |        |                |
| FEDERAL     |   |         |    |   |        |        |                |
| FUNDING     |   |         |    |   |        |        |                |
| REQUEST**   |   |         |    |   |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **ESTIMATED |   |         |    |   |        |        |                |
| TOTAL EMC   |   |         |    |   |        |        |                |
| PROJECT     |   |         |    |   |        |        |                |
| BUDGET:**   |   |         |    |   |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
|             | * |         |    | * |        |        |                |
|             | * |         |    | * |        |        |                |
|             | Y |         |    | Y |        |        |                |
|             | E |         |    | E |        |        |                |
|             | A |         |    | A |        |        |                |
|             | R |         |    | R |        |        |                |
|             | 1 |         |    | 2 |        |        |                |
|             | * |         |    | * |        |        |                |
|             | * |         |    | * |        |        |                |
|             |   |         |    |   |        |        |                |
|             | * |         |    | * |        |        |                |
|             | * |         |    | * |        |        |                |
|             | T |         |    | T |        |        |                |
|             | O |         |    | O |        |        |                |
|             | T |         |    | T |        |        |                |
|             | A |         |    | A |        |        |                |
|             | L |         |    | L |        |        |                |
|             | B |         |    | B |        |        |                |
|             | U |         |    | U |        |        |                |
|             | D |         |    | D |        |        |                |
|             | G |         |    | G |        |        |                |
|             | E |         |    | E |        |        |                |
|             | T |         |    | T |        |        |                |
|             | * |         |    | * |        |        |                |
|             | * |         |    | * |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **A.        | * |         |    | * |        |        |                |
| Federal**   | * |         |    | * |        |        |                |
|             | \ |         |    | \ |        |        |                |
|             | $ |         |    | $ |        |        |                |
|             | * |         |    | * |        |        |                |
|             | * |         |    | * |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **B.        | * |         |    | * |        |        |                |
| Applicant** | * |         |    | * |        |        |                |
|             | \ |         |    | \ |        |        |                |
|             | $ |         |    | $ |        |        |                |
|             | * |         |    | * |        |        |                |
|             | * |         |    | * |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **C.        | * |         |    | * |        |        |                |
| State**     | * |         |    | * |        |        |                |
|             | \ |         |    | \ |        |        |                |
|             | $ |         |    | $ |        |        |                |
|             | * |         |    | * |        |        |                |
|             | * |         |    | * |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **D.        | * |         |    | * |        |        |                |
| Local**     | * |         |    | * |        |        |                |
|             | \ |         |    | \ |        |        |                |
|             | $ |         |    | $ |        |        |                |
|             | * |         |    | * |        |        |                |
|             | * |         |    | * |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **E.        | * |         |    | * |        |        |                |
| Other**     | * |         |    | * |        |        |                |
|             | \ |         |    | \ |        |        |                |
|             | $ |         |    | $ |        |        |                |
|             | * |         |    | * |        |        |                |
|             | * |         |    | * |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **F.        | * |         |    | * |        |        |                |
| Program     | * |         |    | * |        |        |                |
| Income**    | \ |         |    | \ |        |        |                |
|             | $ |         |    | $ |        |        |                |
|             | * |         |    | * |        |        |                |
|             | * |         |    | * |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+
| **G.        | * |         |    | * |        |        |                |
| Total**     | * |         |    | * |        |        |                |
|             | \ |         |    | \ |        |        |                |
|             | $ |         |    | $ |        |        |                |
|             | * |         |    | * |        |        |                |
|             | * |         |    | * |        |        |                |
+-------------+---+---------+----+---+--------+--------+----------------+

![](media/image1.wmf){width="1.4604166666666667in"
height="0.2902777777777778in"}![](media/image1.wmf){width="1.4604166666666667in"
height="0.2902777777777778in"}

######## OMB No. 0915-0285, Expiration Date: 6/3/2007

## FORM 2 - INCOME ANALYSIS FORMAT -- FY 2006 EMC (Page 1 of 2)

YEAR 1 \_\_\_\_ YEAR 2 \_\_\_\_

<table>
<colgroup>
<col style="width: 24%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 9%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 7%" />
<col style="width: 1%" />
<col style="width: 14%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2"><strong>Payor Category</strong></td>
<td><p><strong>NUMBER</strong></p>
<p><strong>OF VISITS</strong></p></td>
<td colspan="2"><strong>Average Charge Per Visit</strong></td>
<td colspan="2"><p><strong>TOTAL CHARGES</strong></p>
<p><strong>(a * b)=(c)</strong></p></td>
<td colspan="2"><strong>Average Adjustment Per Visit</strong></td>
<td><p><strong>Amount Billed</strong></p>
<p><strong>[c-(a*d)]</strong></p></td>
<td colspan="2"><p><strong>Collection Rate</strong></p>
<p><strong>(%)</strong></p></td>
<td><p><strong>Projected Income</strong></p>
<p><strong>(e * f)</strong></p></td>
<td colspan="2"><strong>Actual Accrued Income Past 12
Months</strong></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td><strong>(a)</strong></td>
<td colspan="2"><strong>(b)</strong></td>
<td colspan="2"><strong>(c)</strong></td>
<td colspan="2"><strong>(d)</strong></td>
<td><strong>(e)</strong></td>
<td colspan="2"><strong>(f)</strong></td>
<td><strong>(g)</strong></td>
<td colspan="2"><strong>(h)</strong></td>
</tr>
<tr class="odd">
<td colspan="15"><strong>FEE For SERVICE</strong></td>
</tr>
<tr class="even">
<td colspan="2">Medicaid: Medical</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Medicaid: EPSDT (if different from medical rate)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Medicaid: Dental</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Medicaid: Behavioral</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Medicaid: other fee for Service</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Medicaid</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Subtotal: Medicaid</strong></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Medicare: all inclusive FQHC rate</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Medicare: other Fee for Service</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Subtotal: Medicare</strong></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Private Insurance (Medical)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Private Insurance (Dental)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Private Insurance (Behavioral)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Self-Pay: 100% charge, no discount (Medical)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Self-Pay: Sliding Fee Scale discounts (Medical)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Self-Pay: 0% of chare, full discount (Medical)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Self-Pay: 100% charge, no discount (Dental)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Self-Pay: Sliding Fee Scale discounts (Dental)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Self-Pay: 0% of chare, full discount (Dental)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Self-Pay: 100% charge, no discount ( Behavioral)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Self-Pay: Sliding Fee Scale discounts (Behavioral)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Self-Pay: 0% of chare, full discount (Behavioral)</td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Subtotal: Private Pay</strong></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Total Fee For Service</strong></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="15"><strong>MANAGED CARE - CAPITATED RATE
INCOME</strong></td>
</tr>
<tr class="odd">
<td><strong>CONTRACT NAME</strong></td>
<td colspan="3">Average Members Per Month</td>
<td colspan="2">Number of Months</td>
<td colspan="2">Rate Per Member Per Month</td>
<td colspan="3">Risk Pool Adj. &amp; Other Allowances</td>
<td colspan="3">Projected Gross Income</td>
<td>Collection Rate</td>
</tr>
<tr class="even">
<td>Medicaid:</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td>Medicare</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td>Commercial</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>Total Managed Care/Capitated</strong></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="6">Encounters</td>
<td colspan="5">Avg Charge Per Encounter</td>
<td colspan="3">Total Charges</td>
</tr>
<tr class="odd">
<td><strong>Managed Care Charges</strong></td>
<td colspan="6"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
</tbody>
</table>

*OMB No. 0915-0285, Expiration Date: 6/3/2007*

**FORM 2 - INCOME ANALYSIS FORMAT** (Page 2 of 2)

YEAR 1 \_\_\_\_ YEAR 2 \_\_\_\_

  ------------------ --------- -- --------- -- --------- ---------------- ---------- --- -- ---- ---------- --------------
  **Total Program                                                                                           
  Income \-- Summary                                                                                        
  Tables**                                                                                                  

  **Worksheet                                            **Estimated                                        
  Summary**                                              Program Income                                     
                                                         Allocation\***                                     

  Encounters                                             CHC                                                

  Average Charge Per                                     MHC                                                \*Estimated
  Encounter                                                                                                 Program Income
                                                                                                            should be
                                                                                                            distributed to
                                                                                                            the Programs
                                                                                                            within your
                                                                                                            scope of
                                                                                                            project.

  Total Gross                                            HCH                                                
  Charges                                                                                                   

  Adjustments to                                         PHPC                                               
  Charges                                                                                                   

  Amount Billed                                          **TOTAL**                                          

  Adjustment for                                                                                            
  Uncollectables                                                                                            

  **Budget Expected                                                                                         
  Program Income**                                                                                          

  Actual Program                                                                                            
  Income Previous 12                                                                                        
  Months                                                                                                    

  **OTHER INCOME**                                                                                          

                     **CHC**      **MHC**      **HCH**                    **PHPC**               **Total    
                                                                                                 Other      
                                                                                                 Income**   

  Applicant Income                                                                                          

  State Funds                                                                                               

  Local Funds                                                                                               

  Other Support                                                                                             

  Other Federal                                                                                             
  Grants                                                                                                    

  Contributions                                                                                             

  Fund Raising                                                                                              

  Foundation Grants                                                                                         

                                                                                                            

  Subtotal Other                                                                                            
  Support                                                                                                   

  **Total Other                                                                                             
  Income**                                                                                                  

  **TOTAL                                                                                                   
  NON-FEDERAL                                                                                               
  SHARE**                                                                                                   
  ------------------ --------- -- --------- -- --------- ---------------- ---------- --- -- ---- ---------- --------------

[]{#_Ref84847978 .anchor}

### Instructions for Completing Form 2: Income Analysis

The Income Analysis Worksheet provides a format for presenting the
estimated non-federal revenues for the budget in the application. The
narrative should be used to fully describe the information presented on
this worksheet. The information presented in the worksheet should be
developed based upon the currently approved scope of project. It should
not include revenues expected from any requested supplemental
improvements 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 State or Local grants and other local
> or private support received to support the applicant's programs.
> Generally, this revenue provides support for the provision of medical
> or support services, but is not considered or based upon revenue
> generated from charges for providing the health service to a patient.

The categories presented in the worksheet may not describe all of the
categories of Fee for Service revenue, Contractor or Other Income
categories used by the applicant organization. Two additional lines are
provided in each revenue source for applicant-defined categories. The
categories presented may also be redefined in the narrative to the
worksheet as necessary to clearly identify revenue sources.

**Use the following steps for projecting revenue and present Years 1 and
2 of the project separately using the attached FORM 2: Income Analysis
Format.**

[SPECIAL INSTRUCTIONS FOR FEE FOR SERVICE:]{.underline}

1.  Enter in column (a) the number of encounters that will be covered by
    each type of payment source: Medicaid, Medicare, other third-party
    payors and patient self-pay (categorized by 100 percent pay, sliding
    fee pay and 0 percent self pay).

2.  Enter in column (b) the average charge per encounter by payor
    category.

3.  Column (c), Total Charges (columns (a)\*(b)), needs to be calculated
    for each payment source.

4.  Enter in column (d) the average adjustment of the average charge per
    encounter. A negative number will reduce and a positive number will
    increase the Billed Amount calculated in column (e). Adjustments in
    this column would relate to:

```{=html}
<!-- -->
```
a)  Projected disallowance or discounts to the average charge per visit.

b)  Adjustments to the FQHC or Prospective Payment System established
    reimbursement rate or the cost based reimbursement expected as a
    result of completion of a cost reimbursement report.

c)  Other adjustments which the applicant defines in the narrative to
    this worksheet.

```{=html}
<!-- -->
```
5.  Column (e) the total Amount Billed by payment source needs to be
    calculated by utilizing the formula \[c-(a\*d)\].

6.  Enter in column (f) the estimated collection rate (%) by payor
    category.

7.  Projected income (columns (e)\*(f)) needs to be calculated in
    column (g) for each payor category.

8.  Column (h) represents 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 to this worksheet.

[SPECIAL INSTRUCTIONS FOR MANAGED CARE OR CAPITATED
ARRANGEMENTS:]{.underline}

1.  The Projected Gross Income needs to be calculated using the
    information inputted into the third, fourth and fifth columns in
    this section. The calculation is **((average members per month X
    number of months X rate per member month) + risk pool adj. & other
    allowances = projected gross income).**

2.  RISK POOL ADJ. & OTHER ALLOWANCES, which could include a cost based
    wrap around, should be explained in the narrative to the worksheet.

3.  The applicant must describe in the narrative to the worksheet each
    managed care or capitated rate program included in the budget. For
    each program or contract, please identify the contractor's name and
    the services for which the applicant is at risk. Provide the current
    number of enrollees and the amount of support for the projected
    number of enrollees included in the current budget.

-   Examples of Fee for Service Income are revenues from filing private
    insurance claims, minimum fees charged after a sliding fee scale
    adjustment is applied, payments received from charges to patients on
    a fee for service basis and co-pays for managed care participants.

-   Non-Fee for Service Income would include interest income and
    contracts to serve as Medical Director of a nursing home.

-   Examples of Other Grant Income and State and Local support would be
    grants for construction, equipment or other activities that support
    the project, but for which the revenue is not based upon services
    provided, encounters or charges for encounters

[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. It is
    generated from information input into the previous program income
    sections of the worksheet.

2.  The Estimated Program Income Allocation table will be used by the
    OGM to determine the Estimated Program Income used on the 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.

[SPECIAL INSTRUCTIONS FOR STATE, LOCAL & OTHER OPERATIONAL
FUNDING]{.underline}

1.  List by amount, source, and purpose.

2.  Include the source and value of in-kind donations in this
    description, including donated pharmaceuticals, such as samples.

3.  Distribute the funding by program in which the funds will be used.

4.  Provide additional information in the narrative to this worksheet.

    ![](media/image1.wmf){width="1.4604166666666667in"
    height="0.2902777777777778in"}![](media/image1.wmf){width="1.4604166666666667in"
    height="0.2902777777777778in"}

##### FORM 3 -- FY 2006 EMC SERVICE SITE TABLE

*Instructions: Identify **only those sites proposed for an EMC
expansion** from your current Form 5-Part B/Exhibit B (from the most
recently approved service area competition, change in scope, or
non-competing continuation application). Also note any site(s) to be
relocated and the site(s) that will replace them.*

+---------------------------------+------------------------------------+
| SITE #1                         | SITE #2                            |
+---------------------------------+------------------------------------+
| EMC SITE RELOCATION? *(if yes,  | EMC SITE RELOCATION? *(if yes,     |
| check one of the following):*   | check one of the following):*      |
|                                 |                                    |
| Site to be closed or New        | Site to be closed or New           |
| replacement site                | replacement site                   |
|                                 |                                    |
| 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/will be opened:   | Date site was/will be opened:      |
|                                 |                                    |
| Name of service site:           | Name of service site:              |
|                                 |                                    |
| Physical Address:               | Physical Address:                  |
|                                 |                                    |
| City State Zip (9 digit         | City State Zip (9 digit required)  |
| required)                       |                                    |
|                                 | Phone No. Fax No.                  |
| Phone No. Fax No.               |                                    |
|                                 | Congressional District:            |
| Congressional District:         |                                    |
|                                 | County Name:                       |
| County Name:                    |                                    |
|                                 | Service Area:                      |
| Service Area:                   |                                    |
|                                 | Census tracts:                     |
| Census tracts:                  |                                    |
|                                 | Urban/Rural/Sparsely Populated:    |
| Urban/Rural/Sparsely Populated: |                                    |
|                                 | Other HRSA Funding Sources:        |
| Other HRSA Funding Sources:     |                                    |
+---------------------------------+------------------------------------+
| SITE #3                         | SITE #4                            |
+---------------------------------+------------------------------------+
| EMC SITE RELOCATION? *(if yes,  | EMC SITE RELOCATION? *(if yes,     |
| check one of the following):*   | check one of the following):*      |
|                                 |                                    |
| Site to be closed or New        | Site to be closed or New           |
| replacement site                | replacement site                   |
|                                 |                                    |
| 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/will be opened:   | Date site was/will be opened:      |
|                                 |                                    |
| Name of service site:           | Name of service site:              |
|                                 |                                    |
| Physical Address:               | Physical Address:                  |
|                                 |                                    |
| City State Zip (9 digit         | City State Zip (9 digit required)  |
| required)                       |                                    |
|                                 | Phone No. Fax No.                  |
| Phone No. Fax No.               |                                    |
|                                 | Congressional District:            |
| Congressional District:         |                                    |
|                                 | County Name:                       |
| County Name:                    |                                    |
|                                 | Service Area:                      |
| Service Area:                   |                                    |
|                                 | Census tracts:                     |
| Census tracts:                  |                                    |
|                                 | Urban/Rural/Sparsely Populated:    |
| Urban/Rural/Sparsely Populated: |                                    |
|                                 | Other HRSA Funding Sources:        |
| Other HRSA Funding Sources:     |                                    |
+---------------------------------+------------------------------------+

NOTE: Add additional pages as necessary.

![](media/image1.wmf){width="1.4604166666666667in"
height="0.2902777777777778in"}![](media/image1.wmf){width="1.4604166666666667in"
height="0.2902777777777778in"}

# [Attachment 2: Format for the Line Item Budget Justification]{.smallcaps}

## Line-Item Budget Justification \[Required Format\]

The following required format is provided to assist you in developing
your line-item budget justification. Additional budget narrative should
be attached to fully describe your proposal (see instructions in
*section v. Budget Justification*). This format is provided as a broad
outline. It should reflect the total necessary costs for the proposed
EMC project. **Any significant changes in the costs of each object class
from Year 1 to Year 2 should be fully described and justified in the
budget narrative, as well as the impact on the Federal request.**

**REVENUE:** [Total Org.]{.underline} [Year 1]{.underline} [Year
2]{.underline}

**PATIENT SERVICE INCOME** \$ \$ \$

(including Pharmacy)

**LOCAL & STATE GRANTS** \$ \$ \$

(Break out by fund source)

**LOCAL FUNDING** \$ \$ \$

**FEDERAL BPHC 330 GRANT** \$ \$ \$

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

(Break out by fund source)

**TOTAL: REVENUE \$ \$ \$**

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

**PERSONNEL**: \$ \$ \$

**FRINGE BENEFITS**: Break out each

portion of Fringe Benefits: \$ \$ \$

> FICA
>
> Retirement, etc.

**TOTAL: PERSONNEL & FRINGE \$ \$ \$**

**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 \$ \$ \$**

**EQUIPMENT:**

List project equipment items

**TOTAL: EQUIPMENT \$ \$ \$**

**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 \$ \$ \$**

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

**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 \$ \$ \$**

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

**TOTAL: A&R** \$ **\$ \$**

**OTHER**: [Total Org.]{.underline} [Year 1]{.underline} [Year
2]{.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 per site) \$ \$ \$

Marketing/Outreach \$ \$ \$

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

Technical Assistance \$ \$ \$

**TOTAL: OTHER \$ \$ \$**

**TOTAL: ALL BUDGET \$ \$ \$**

####### 

####### 

####### 

####### 

####### 

# [Attachment 3:]{.smallcaps} [Service Delivery Plan and Business Plan]{.smallcaps}

## Guidelines For Developing the

## Service Delivery Plan and the Business Plan

The following components are intended for use in both the service
delivery and business plans. Presenting the plans in \"landscape\" print
format may facilitate easier reading and usage. Please refer to *section
IV. Application and Submission Information* for more information about
completing these plans.

**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
Program Narrative.

**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.
Objectives are descriptions of desired, measurable, time‑limited results
or outcomes. These 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.
Objectives can be either short‑term (less than 1 year) or long‑term (1
year or longer). 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.

**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.

## Format for the Service Delivery Plan & Business Plan Presentations

This format is provided for the Service Delivery and Business Plan
presentations. Additional information may be provided to fully describe
your proposal:

+----------+-------------+--------------+---------+---------+-------+
| Prob     |             |              |         |         |       |
| lem/Need |             |              |         |         |       |
| St       |             |              |         |         |       |
| atement: |             |              |         |         |       |
| Diabetes |             |              |         |         |       |
| is a     |             |              |         |         |       |
| common   |             |              |         |         |       |
| d        |             |              |         |         |       |
| iagnosis |             |              |         |         |       |
| among    |             |              |         |         |       |
| patients |             |              |         |         |       |
| of CHC,  |             |              |         |         |       |
| Inc.     |             |              |         |         |       |
| CHC,     |             |              |         |         |       |
| Inc.     |             |              |         |         |       |
| aims to  |             |              |         |         |       |
| improve  |             |              |         |         |       |
| care and |             |              |         |         |       |
| quality  |             |              |         |         |       |
| of life  |             |              |         |         |       |
| for its  |             |              |         |         |       |
| clients  |             |              |         |         |       |
| with     |             |              |         |         |       |
| diabetes |             |              |         |         |       |
| by       |             |              |         |         |       |
| red      |             |              |         |         |       |
| esigning |             |              |         |         |       |
| the      |             |              |         |         |       |
| delivery |             |              |         |         |       |
| of       |             |              |         |         |       |
| health   |             |              |         |         |       |
| care     |             |              |         |         |       |
| s        |             |              |         |         |       |
| ervices. |             |              |         |         |       |
+----------+-------------+--------------+---------+---------+-------+
| Goals/Ob | Key Action  | Expected     | Data,   | Pers    | Com   |
| jectives | Steps       | Outcome      | Eva     | on/Area | ments |
|          |             |              | luation | Resp    |       |
|          |             |              | &       | onsible |       |
|          |             |              | Meas    |         |       |
|          |             |              | urement |         |       |
+----------+-------------+--------------+---------+---------+-------+
| A. To    | A.1.(a)     | A.1.(a) By   | A.1(a)  | A.1.(a) | A.    |
| improve  | Track       | 5/06, 90% of | Medical | Nursing | 1.(a) |
| the      | patients to | patients     | Records | Staff   | He    |
| health   | insure they | have had a   |         |         | althy |
| status   | have annual | retinal eye  | A.1(b)  | A.1.(b) | P     |
| of       | retinal eye | exam in the  | Data,   | Pers    | eople |
| patients | exams and   | last 12 mts  | Eval &  | on/Area | 2010  |
| with     | foot exams. |              | Meas    |         | Goals |
| diabetes | Refer as    | A.1.(b)      |         | A.1.(c) | and   |
|          | needed      | Expected     | A.1.(c) | Pers    | Obj   |
| A.1. At  |             | Outcome      | Data,   | on/Area | (5-1  |
| least    | A.1 (b)     |              | Eval &  |         | th    |
| 90% of   | Action step | A.1.(c)      | Meas    | A.2.(a) | rough |
| patients | 2 for       | Expected     |         | Pers    | 5     |
| will     | Objective 1 | Outcome      | A.2.(a) | on/Area | -17). |
| have had |             |              | Data,   |         |       |
| a        | A.1.(c)     | A.2.(a)      | Eval &  | A.2.(b) | A.    |
| retinal  | Action step | Expected     | Meas    | Pers    | 1.(b) |
| eye exam | 3 for       | Outcome      |         | on/Area | Com   |
| in the   | Objective 1 |              | A.2.(b) |         | ments |
| last 12  |             | A.2.(b)      | Data,   |         |       |
| months   | A.2.(a)     | Expected     | Eval    |         | A.    |
| by 5/06  | Action step | Outcome      | &Meas   |         | 1.(c) |
|          | 1 for       |              |         |         | Com   |
| A.2.     | Objective 2 |              |         |         | ments |
| O        |             |              |         |         |       |
| bjective | A.2 (b)     |              |         |         | A.    |
| (2)      | Action step |              |         |         | 2.(a) |
|          | 2 for       |              |         |         | Com   |
|          | Objective 2 |              |         |         | ments |
|          |             |              |         |         |       |
|          |             |              |         |         | A.    |
|          |             |              |         |         | 2.(b) |
|          |             |              |         |         | Com   |
|          |             |              |         |         | ments |
+----------+-------------+--------------+---------+---------+-------+
| Prob     |             |              |         |         |       |
| lem/Need |             |              |         |         |       |
| St       |             |              |         |         |       |
| atement: |             |              |         |         |       |
| Well     |             |              |         |         |       |
| -managed |             |              |         |         |       |
| human    |             |              |         |         |       |
| r        |             |              |         |         |       |
| esources |             |              |         |         |       |
| are      |             |              |         |         |       |
| critical |             |              |         |         |       |
| to the   |             |              |         |         |       |
| success  |             |              |         |         |       |
| of any   |             |              |         |         |       |
| organ    |             |              |         |         |       |
| ization. |             |              |         |         |       |
+----------+-------------+--------------+---------+---------+-------+
| B.       | B.1.(a)     | B.1.(a) Exam | B.1.(a) | B.1.(a) | B.    |
| Maintain | Each exam   | rooms        | List of | CQI     | 1.(a) |
| well-q   | room will   | properly     | exam    | Team    | Com   |
| ualified | be fully    | equipped     | room    | and     | ments |
| staff    | equipped    |              | equ     | staff   |       |
| for      | for all     | B.1.(b)      | ipment. |         | B.    |
| health   | aspects of  | Expected     |         | B.1.(b) | 1.(b) |
| center.  | patient     | Outcome      | B.1.(b) | Pers    | Com   |
|          | care.       |              | Data,   | on/Area | ments |
| B.1.     |             | B.2.(a)      | Eva     |         |       |
| I        | B.1 (b)     | Expected     | luation | B.2.(a) | B.    |
| mplement | Action step | Outcome      | &       | Pers    | 2.(a) |
| an       | 2 for       |              | Meas    | on/Area | Com   |
| annual   | Objective 1 | B.2.(b)      | urement |         | ments |
| per      |             | Expected     |         | B.2.(b) |       |
| formance | B.2.(a)     | Outcome      | B.2.(a) | Pers    | B.    |
| ev       | Action step |              | Data,   | on/Area | 2.(b) |
| aluation | 1 for       |              | Eva     |         | Com   |
| and      | Objective 2 |              | luation |         | ments |
| employee |             |              | &       |         |       |
| sati     | B.2 (b)     |              | Meas    |         |       |
| sfaction | Action step |              | urement |         |       |
| program. | 2 for       |              |         |         |       |
|          | Objective 2 |              | B.2.(b) |         |       |
| B.2.     |             |              | Data,   |         |       |
| O        |             |              | Eva     |         |       |
| bjective |             |              | luation |         |       |
| (2)      |             |              | &       |         |       |
|          |             |              | Meas    |         |       |
| B.3.     |             |              | urement |         |       |
| O        |             |              |         |         |       |
| bjective |             |              |         |         |       |
| (3)      |             |              |         |         |       |
+----------+-------------+--------------+---------+---------+-------+
| C. Goal  | C.1.(a)     | C.1.(a)      | C.1.(a) | C.1.(a) | C.    |
|          | Action step | Expected     | Data,   | Pers    | 1.(a) |
| C.1.     | 1 for       | Outcome      | Eva     | on/Area | Com   |
| O        | Objective 2 |              | luation |         | ments |
| bjective |             | C.1.(b)      | &       | C.1.(b) |       |
| (1)      | C.1 (b)     | Expected     | Meas    | Pers    | C.    |
|          | Action step | Outcome      | urement | on/Area | 1.(b) |
|          | 2 for       |              |         |         | Com   |
|          | Objective 2 |              | C.1.(b) |         | ments |
|          |             |              | Data,   |         |       |
|          |             |              | Eva     |         |       |
|          |             |              | luation |         |       |
|          |             |              | &       |         |       |
|          |             |              | Meas    |         |       |
|          |             |              | urement |         |       |
+----------+-------------+--------------+---------+---------+-------+

[^1]: In previous documents, application guidances and other materials,
    HRSA has made reference to the School-Based Health Center (SBHC)
    Program. Section 330 of the PHS Act does not include authorization
    for a SBHC Program. Therefore, HRSA will no longer identify SBHCs as
    a separate Health Center Program or category/type of health center;
    however, there will continue to be recognition of school-aged
    children as an underserved population served by health centers. All
    organizations receiving section 330 funding specifically to support
    a SBHC must comply with the requirements of section 330(e),
    Community Health Center Program. Funds to support the SBHC should be
    identified or included in budget presentations as a request for
    section 330(e), CHC Program funding.

[^2]: See previous footnote on p. 5 of this guidance.