Form 0285 waiver 0285 waiver 0285 waiver

OMB No. 0915-0285

  Expiration Date: xx/xx/xxx

DEPARTMENT OF HEALTH

AND HUMAN SERVICES
Health Resources and

Services Administration

REQUEST

FOR WAIVER OF

GOVERNANCE

REQUIREMENTS

FOR HRSA USE ONLY

Application Tracking Number Grant Number

For health centers that are seeking support for MHC, HCH, or PHPC Only as Necessary. REQUEST FOR WAIVERS WILL NOT BE GRANTED IF APPLICANT ALSO RECIEVES OR IS APPROVED FOR CHC FUNDING ²

Are you requesting a waiver of governance requirements?
[_] Yes [_] No [_] Not Applicable

if Yes, answer all questions given below.

Name of Organization:

For applicants with previous waiver approval:
Date of Original Governance

Waiver Request

Date of Waiver Approval by
BPHC Director

Date of Most Recent approval
of Continuation of Waiver
Request (if different)

Nature of Items Currently [_] 51 Percent User Majority

Approved to be Waived [_] Monthly Meetings

Are you requesting the waiver [_] Yes (Complete next question)

be continued? [_] No (Governing Board is in Full Compliance)

If you answered 'Yes' to the previous question, is your waiver request based on arrangements that are different from your original request?

[_]Yes [_] No [_] N/A

Explain progress made toward meeting full compliance?

Nature of Items for New Waiver Request

[_] 51 Percent User Majority

[_] Monthly Meetings [_] Other

All Organizations Requesting Waiver

Describe below the arrangements that are in place to assure appropriate user input and involvement is achieved, as well as plans for achieving compliance.

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.