Form 0285-6b Request for Waiver of Governance Requirements

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 6B: REQUEST FOR WAIVER OF GOVERNANCE REQUIREMENTS		FOR HRSA USE ONLY
		Application Tracking Number	Grant Number
1. Request for Waiver
Name of Organization
1a. Are you requesting a waiver of governance requirements?	[_] Yes [_] No  [_] Not Applicable
2. For applicants with previous waiver
2a. Nature of Items Currently Approved to be Waived	[_] 51 Percent Patient Majority [_] Monthly Meetings
2b. Are you requesting the waiver be continued?	[_] Yes (Complete next question) [_] No (Governing Board is in Full Compliance)
2c. Is your waiver request based on arrangements that are different from your original request? (Answer to this question is mandatory, if you answer 'Yes' to Question 2b.)	[_] Yes [_] No
3. New Waiver Request
3a. Nature of Items for New Waiver Request (Answer to this question is mandatory, if you answer 'Yes' to Question 1a.)	[_] 51 Percent Patient Majority [_] Monthly Meetings
4. All Organizations Requesting Waiver: Describe the appropriate alternative strategies in place that will assure consumer/patient participation and/or regular oversight in the direction and ongoing governance of the organization.
4a. Strategy 1 (Answer to this question is mandatory, if you answer 'Yes' to Question 1a.)
4b. Strategy 2
4c. Other Strategies

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.