Form 0285-6a Board Member Characteristics

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 6 - PART A: CURRENT BOARD MEMBER CHARACTERISTICS	FOR HRSA USE ONLY
	Grantee Name	Application Tracking Number

BOARD MEMBER NAME

BOARD OFFICE

HELD

AREA OF EXPERTISE
(Place asterisk (*) if member derives more than 10% of income from health industry)

HEALTH CENTER PATIENT

LIVE OR WORK IN SERVICE AREA

YEARS OF CONTINUOUS BOARD SERVICE

SPECIAL POPULATION REPRESENTATIVE

(If Yes, specify Special Population)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Gender	Number of Board Members
Male
Female
Unreported
Ethnicity	Number of Board Members
Hispanic Origin
Non-Hispanic or Latino
Unreported
Race	Number of Board Members
White
Native Hawaiian or Other Pacific Islander
Black/African American
American Indian or Alaska Native
Asian
More Than One Race
Unreported

Note: (1) Tribal organizations are exempt from completing Form 6A.

(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) Add additional pages, if needed.

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.