BPAO Site Form (Current Version)

OMB 0960-0629

Benefits Planning, Assistance, and Outreach

Project State Partnership Initiative

Demonstration Site Information Form

1. Project Demonstration SiteName (agencySSA grantee name or city): ________________________________

2. Project Site (provider agency name): ________________________________State: _______________

3. Primary contact person for data:

Last Name: _______________________________ First Name: _________________

Email: _______________________________________

4. Date Site began operation (MM/DD/YY): __ __ /__ __ / __ __

4. Geographic catchment area (check all that are applicable to the demonstration site):

Urban

Suburban

Rural

Geographic area in which the demonstration project is located (check only one):

Urban

Suburban

Rural

5. Site Contact Information:

Full Address:

For assistance with this form, contact Michael West by phone at (804)828-1851, by fax at (804)828-2193, or by e-mail at mwest@vcu.org.

________________________________________________________________________________________________________________________________________________City: _______________________State: ___ ___ Zip Code: __ __ __ __ __ - __ __ __ __

Telephone: (__ __ __) __ __ __ - __ __ __ __

Fax: (__ __ __) __ __ __ - __ __ __ __

Site ID: This identifier is assigned when the site Information is entered, and is required to review or enter either benefit specialist information or beneficiary/recipient information.

Write it down here when the computer gives it to you: ___ ___ ___ ___ ___ ___