Form 0285 Board members 0285 Board members 0285 Board members

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 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 1 hour 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.

BOARD MEMBER CHARACTERISTICS

BOARD MEMBER NAME	BOARD OFFICE HELD	OCCUPATION / AREA OF EXPERTISE	INDICATE IF USER OF HEALTH CENTER SERVICES (YES/NO)	LIVE (L) OR WORK (W) IN SERVICE AREA	YEARS OF CONTINUOUS BOARD SERVICE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Indicate # Board Members by Sex: F = _______ M = ______

Indicate # Board Members by Race/Ethnicity:

Ethnicity: Hispanic or Latino: __________

Race:

White: _______ Black/African American: ______

Asian________ Native Hawaiian or Other Pacific Islander: _______

American Indian & Alaska Native:_______ More Than One Race: _________

NOTES: (1) Please indicate if a board member is a special population representative (MHC, HCH, PHPC).

(2) MHC, HCH, and/or PHPC applicants requesting a waiver of the governance requirements must complete Form 6 – Part B and describe any alternative arrangement for addressing Board requirements including the mechanism for receiving consumer input.

(3) Tribal entities are exempt from Governance Requirements.

(4) Add additional pages if needed