Form 0285 1 0285 1 0285 general information worksheet

OMB No.: 0915-0285. Expiration Date: xx/xx/xxxx
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FOR HRSA USE ONLY
Application Tracking Number

Grant Number

GENERAL INFORMATION WORKSHEET

1. Applicant Information
Applicant Name
Application Type

Existing Grantee

Grant Number

UDS #

Business Entity

[_] Private Nonprofit [_] Public Entity

Organization Type

2. Proposed Service Area

2a. Service Area Designation

2b. Target Population Type

[_]
[_]
[_]
[_]
[_]

Medically Underserved Area (ID#____)
Medically Underserved Population (ID#____)
MUA Application Pending (ID#____)
MUP Application Pending (ID#____)
None of the above
[_] Serving Section 330 (G) - Migrant Health Centers
[_] Serving Section 330 (H) - Homeless Health Centers
[_] Serving Section 330 (I) - Public Housing Health Centers

[_] Urban
[_] Rural

2c. Target Population and Provider Information
Target Population Information

CURRENT NUMBER

Projected at FULL CAPACITY

Total SERVICE AREA POPULATION
Total TARGET POPULATION
Total FTE Medical Providers
Total FTE Dental Providers
Total FTE Behavioral Health Providers
Total FTE Sustance Abuse Service Providers
Users and Encounters by Service Type
CURRENT NUMBER
SERVICE TYPE
Total Medical
Total Dental
Total Mental Health
Total Substance Abuse
Users and Encounters by Population Type

USERS

ENCOUNTERS

Projected at FULL CAPACITY
USERS

ENCOUNTERS

POPULATION TYPE

(b)
CURRENT
NUMBER

Number at End
of Yr1

(c)
NUMBER AFTER
2 YEAR

NUMBER AT
FULL CAPACITY

(d)
CHANGE IN
NEW USERS
AFTER 2 YEARS
(c-b)

(e)
PERCENT
CHANGE IN
NEW USERS
AFTER 2 YEARS
(d/b)*100

Users Encounters Users Encounters Users Encounters Users Encounters Users Encounters Users Encounters
General Community
Migrant/Seasonal
Farmworkers
Public Housing Residents
Homeless Persons
TOTAL

3. Funding Preference
Indicate if the following preference is requested:
[_] Sparsely Populated (persons/square mile: 7)
Please attach evidence that supports your preference request (e.g., census bureau documentation)

4. Funding Priority
Select priority type you are requesting below:
[_] Multi-county (Must demonstrate that a minimum of 15 percent of the total target population will come
from county(ies) other than the eligible high priority county) (PI 2 Only)

5. Target Population by County
County Name

Targeted County

Number From Total
Target Population

Percent of
Target Population

County A
County B
Total
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 this collection of information is
estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, 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 10-33, Rockville, Maryland, 20857.