Form 0285 community cha 0285 community cha 0285 community characteristics

OMB No. 0915-0285

Expiration Date:

COMMUNITY CHARACTERISTICS

Instructions to Applicants: Community-wide and target population data should reflect all counties, cities, etc., in the applicant’s proposed scope of the project. Community-wide data should include the total number of persons and the percent of the total population in the service area for each characteristic. Target population data is a subset of the community-wide data. Target population includes the number of persons and the percent of the total population the health center targets for each characteristic. Estimates are acceptable. Please do not utilize user/patient data reported in the Uniform Data System to report target population data.

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 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.

	CHARACTERISTIC	COMMUNITY WIDE DATA # %		TARGET POPULATION DATA # %
Race/Ethnicity	Ethnicity:
	Hispanic
	Race:
	Black or African-American
	White
	American Indian or Alaskan Native
	Asian
	Native Hawaiian or Other Pacific Islander
	More Than One Race
	Total Population
INCOME AS A PERCENT OF POVERTY LEVEL	Below 100%
	100-199 percent
	200 percent and above
	Unknown
PRIMARY THIRD PARTY PAYMENT SOURCE	Medicaid/Capitated
	Medicaid/Not Capitated
	Medicare
	Other Public Insurance
	Private Insurance, including capitation
	None/Uninsured
SPECIAL POPULATIONS	Migrant/ Seasonal Farmworkers and Families
	Homeless People
	HIVAIDS-Infected Persons
	Persons with Mental Health/Substance Abuse
	Residents of Public Housing
	School Age Children
	Infants Birth to 2 years of Age
	Women Age 25 - 44
	Persons Age 65 and Older
	Other: (Please specify)