Form 0285 affiliation c 0285 affiliation c 0285 hc affiliation checklist

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 30 minutes 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.

HEALTH CENTER AFFILIATION CHECKLIST

STAFFING:		YES	NO
1) The center directly employs the CFO, CMO and the core staff of full-time primary care providers.
2) The center directly employs all non-provider health center staff.
If NO to question 2 or 3, the CEO of the center retains the authority to select and dismiss staff assigned to the center. Please cite reference document and page #.       (If NO to question 1 or 2, the applicant must submit a request for a good cause exception. Please see PIN 98-24.)
GOVERNANCE:		YES	NO
3) The Governing Board structure is in compliance with all section 330 requirements.
4) The Governing Board retains its full authorities, responsibilities and functions as prescribed in legislation/regulations/HRSA guidelines in regard to the following as identified below.
5) The arrangements presented in the affiliation agreements do not compromise the Board authorities or limit its legislative and regulatory mandated functions and responsibilities. (Examples of compromising arrangements are: overriding approval or veto authority by another entity; dual majority requirements; super-majority requirements; or hiring and dismissal of the CEO).
	Reference Document		Page #
board composition	     		     
executive committee function and composition	     		     
selection of board chairperson	     		     
selection of members	     		     
strategic planning	     		     
approval of the annual budget of the center	     		     
directly employs, selects/dismisses and evaluates the Chief Executive Officer/Executive Director	     		     
adoption of policies and procedures for personnel and financial management	     		     
establishes center priorities	     		     
establishes eligibility requirements for partial payment for services	     		     
provides for an independent audit	     		     
evaluation of center activities	     		     
adoption of center’s health care policies including scope and availability of services, location, hours of operation and quality of care audit procedures	     		     
existence of a conflict of interest policy	     		     
contains appropriate provisions around the activities to be performed, time, schedules, the policies and procedures to be followed in carrying out the agreement, and the maximum amount of money for which the grantee may become liable to the contractor under the agreement;	     		     
requires the contractor to maintain appropriate financial, program and property management systems and records in accordance with 45 CFR Part 74 and provides the center, DHHS and the U.S. Comptroller General with access to such records;	     		     
requires the submission of financial and programmatic reports to the health center;	     		     
complies with Federal procurement standards or grant requirements including conflict of interest standards;	     		     
subject to termination (with administrative, contractual and legal remedies) in the event of breach by the contractor.	     		     
CONTRACTING:	YES		NO
6) The center has justified the performance of the work by a third party. Please cite reference doc and page #.
7) Written affiliation agreement(s) comply with current Department of Health and Human Services (HHS) policies.
INCLUDE LIST AND COPIES OF ALL RELEVANT AND CITED DOCUMENTS

I certify that the information contained herein is accurate to the best of my knowledge.

Printed Name Signature of Governing Board Chairperson Date