Form 0285 planning 0285 planning 0285 planning worksheet

OMB No. 0915-0285

Expiration Date:

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 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 12 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.

PLANNING GRANT GENERAL INFORMATION WORKSHEET

Applicant Name:

     

Name of Contact Person:

     

Mailing/Street Address:

     

Title:

     

City, State, Zip:

     

Email:

     

Phone:

     

Fax:

     

Proposed Service Area (City(ies), State)

     

All proposed COUNTIES within proposed service area:

     

Relevant ZIP CODES within proposed service area:

     

PLEASE CHECK ONE ON EACH LINE:

Private, Non Profit

Public Entity

Medically Underserved Area (MUA)

Medically Underserved Population (MUP)

Applying for MUA/MUP

Urban

Rural

Sparsely Populated (persons/square mile:      )

PLEASE CHECK ALL THAT APPLY:

Tribal Entity/Urban Indian

Public Health Dept

Hospital

Faith-Based Org

Local Govt

University

CURRENT RECIPIENT OF BPHC FUNDING?

YES

NO

IF YES, PLEASE CHECK ALL THAT APPLY:

Section 330 Grantee (i.e., CHC, MHC, HCH, or PHPC)

National Training/TA Cooperative Agreement Please Describe:      

Primary Care Association

Other, Please Describe:      

PREFERENCE REQUESTED Must provide Census Bureau documentation as evidence that the ENTIRE proposed Service Area is sparsely populated (7 of fewer persons/sq.mi.)

Total Federal Funding Requested

Total Project Budget

Service Area is Sparsely Populated (persons/mile2 :     )

YES

NO

YEAR 1

     

     

PURPOSE OF PLANNING GRANT APPLICATION: (PLEASE CHECK ALL THAT APPLY)

Conducting a comprehensive needs assessment

Applying for MUA/MUP designation and/or other essential designations

Designing an appropriate health care service delivery model, based on the comprehensive needs assessment

Efforts to secure financial, professional, and technical assistance

Increasing community involvement in the development and/or operational stages of a comprehensive health center

Developing linkages/building partnerships with other providers in the community