Form 0285-1a General Info Worksheet

OMB No.: 0915-0285. Expiration Date: 08/31/2010

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FORM 1A: GENERAL INFORMATION WORKSHEET

FOR HRSA USE ONLY

Application Tracking Number

Grant Number

 

 

1. Applicant Information

Applicant Name

 

Application Type

 

Existing Grantee

 

Grant Number

 

UDS #

 

Business Entity

Organization Type

(Please select one ONLY)

[_] Tribal

 [_] Private-Non Profit

 [_] Public

Organization Characteristics

 [_] Urban Indian

 [_] Faith based
 [_] Hospital
 [_] State government

[_] City/County/Local Government or Municipality

 [_] University

 [_] Community based organization

[_] Other

If ‘Other’, please specify: __________

2. Proposed Service Area

Applicants applying for Community Health funding should provide at least one designated service area ID being proposed to serve under an MUA or MUP.

2a. Service Area Designation

(Use commas to separate multiple IDs)

 [_] Medically Underserved Area (ID#____)
 [_] Medically Underserved Population (ID#____)
 [_] MUA Application Pending (ID#____)
 [_] MUP Application Pending (ID#____)
 [_] Serving Section 330 (G) - Migrant Health Centers
 [_] Serving Section 330 (H) - Homeless Health Centers
 [_] Serving Section 330 (I) - Public Housing Health Centers

2b. Target Population Type

 [_] Urban
 [_] Rural

GENERAL INFORMATION Refer to the guidance to accurately complete the below information.

2c. Target Population and Provider Information

Target Population Information	Current Number	Projected at End of Project Period
Total Service Area Population
Total Target Population
Total FTE Medical Providers
Total FTE Dental Providers
Total FTE Behavioral Health Providers
Total FTE Substance Abuse Service Providers
Data reported below should not be duplicated for patients and visits.

Patients and Visits by Service Type

Service Type	Current Number		Projected at End of Project Period
	Patients	Visits	Patients	Visits
Total Medical
Total Dental
Total Mental Health
Total Substance Abuse

Patients and Visits by Population Type

POPULATION TYPE

Current

Number

(b)

Number at End

of Year 1

Number After

Year 2

Number at End

of Project Period

 

Patients

Visits

Patients

Visits

Patients

Visits

Patients

Visits

General Community

 

 

 

 

 

 

 

 

 

 

 

Migrant/Seasonal Farm workers

 

 

 

 

 

 

 

 

 

 

 

Public Housing Residents

 

 

 

 

 

 

 

 

 

 

 

Homeless Persons

 

 

 

 

 

 

 

 

 

 

 

TOTAL

 

 

 

 

 

 

 

 

 

 

 

Note: The following sections are not applicable for New Access Point applications: Target Population by County.

3. Funding Preference

Indicate if the following preference is requested:

[_] Sparsely Populated (persons/square mile:___)

Please attach evidence that supports your preference request (e.g., census bureau documentation)

4. Funding Priority

Select priority type you are requesting below:

[_] Percent of Target Population at or below 100 percent of poverty to be served by the applicant exceeds 30 percent

Percent of Target Population at or below 100 percent of poverty:______

Please attach evidence that the target population (in entire proposed NAP Service Area) at or below 100% of poverty exceeds 30 percent (e.g., census bureau documentation).

5. Target Population by County
County Name	Targeted County	Number From Total Target Population	Percent of Target Population
Total

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.