Form 0285 other site ac 0285 other site ac 0285 other site activities

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

OTHER ACTIVITIES/LOCATIONS
ACTIVITY/LOCATION #
Type of Activity
Frequency of Activity
Description of Activity
Type of Location(s)
where
Activity is Conducted
ACTIVITY/LOCATION #
Type of Activity
Frequency of Activity
Description of Activity
Type of Location(s)
where
Activity is Conducted
ACTIVITY/LOCATION #
Type of Activity
Frequency of Activity
Description of Activity
Type of Location(s)
where
Activity is Conducted
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 .5 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.