Form 0285 need for assi 0285 need for assi 0285 need for assistance

OMB No. 0915-0285

Expiration Date:

Need for Assistance

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 6 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.

Please see instructions for completing and scoring the NFA Worksheet. Type or print all responses clearly.

SECTION 1: CORE BARRIERS (Maximum 45 points)
Respond to all three (3) of the CORE BARRIERS. Please write in the Barrier response in column (a), the data source for the response in column (b), date of the data in column (c), state whether the data provided is based on a geographic service area or a specific target population (e.g. migrant or homeless persons) in column (d) and, if using an alternate data source, provide a brief explanation as to why that source is more appropriate in column (g). As a reminder, applicants MUST use the data source provided in the NFA Data Resource Guide to respond to Barrier (b): Percent of Population at or Below 200 percent of poverty.
Question (a)	Barrier (b)	Response (c)	Data Source (d)	Year or date to which data apply (e)	Identify Target Population for data (f)	Explanation for Use of Alternate Data Source (g)
a.	Population to Primary Care Physician Ratio
b.	Percent of Population at or Below 200 percent of poverty					Not Applicable
c.	Percent of Population Uninsured
SECTION 2: OTHER BARRIERS (Maximum 30 points)
Respond to two (2) out of five (5) of the OTHER BARRIERS. Please write in the Other Barrier letter for the selected barrier in column (a), the question subject information in column (b), the Other Barrier response in column (c), the data source for the response in column (d), date of the data in column (e), state whether the data provided is based on a geographic service area or a specific target population (e.g. migrant or homeless persons) in column (e), and if using an alternate data source, provide a brief explanation as to why that source is more appropriate in column (g). As a reminder, applicants MUST use the data source provided in the NFA Data Resource Guide to respond to Barrier (g): 12-Month Average Unemployment Rate.
Question (a)	List Barrier (e.g., “Travel Time”) (b)	Response (c)	Data Source (d)	Year or date to which data apply (e)	Identify Target Population for data (f)	Explanation for Use of Alternate Data Source (g)
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SECTION 3: CORE DISPARITIES (Maximum 15 points)
Respond to one (1) Disparity indicator from within each of the five (5) Disparity categories numbered 1 through 5. Please write in the Disparity category indicator # in column (a), list the specific Disparity Factor Indicator in column (b), the disparity response in column (c), the data source for the response in column (d), date of the data in column (e), state whether the data provided is based on a geographic service area or a specific target population (e.g. migrant or homeless persons) in column (f), and, if using an alternate data source, provide a brief explanation as to why that source is more appropriate in column (g). If providing an “other” disparity category factor, the applicant must define the factor (which must be related and specific to that disparity category) and present the national benchmark as well as the response for that Disparity factor.
Indicator # (e.g. “1 (e)”). (a)		Disparity Factor Indicator (e.g., “Diabetes Prevalence for ages 20-39”) (b)		Response (c)	Data Source (Provide benchmark if using “Other”) (d)		Year or date to which data apply (e)		Identify Target Population for data (f)		Explanation for Use of Alternate Data Source (g)
Diabetes/Obesity: 1.( )
CV Disease: 2.( )
Asthma, Resp. Disease: 3.( )
Pre & Perinatal Health 4.( )
Mental Hlth,/ Sub. Abuse . ( )
SECTION 4: OTHER DISPARITIES (Maximum 10 points)
Respond to five (5) out of ten (10) of the Disparity factors numbered 6 through 15. Please write in the disparity indicator # from Section 1 in the first column, list the specific Disparity Factor Indicator in the second column, the disparity response in the third column, the data source for the response in the fourth column, date of the data in the fifth column, state whether the data provided is based on a geographic service area or a specific target population (e.g. migrant or homeless persons) in the sixth column, and if using an alternate data source, provide a brief explanation as to why that source is more appropriate in the seventh column. If providing a disparity factor under “Other,” the applicant must define the factor (which must be a disparity related to the population or area to be served), present the national benchmark as well as the response for that factor.
Indicator # (e.g. “7”) (a)	Disparity Factor Indicator (e.g., “HIV Seroprevalence”) (b)		Response (c)	Data Source (Provide benchmark if using “Other”) (d)		Year or date to which data apply (e)		Identify Target Population for data (f)		Explanation for Use of Alternate Data Source (g)
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