Form 0285-Proposal Cove 0285-Proposal Cove Capital Improvement_Investment Proposal Cover Page

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

PROPOSAL COVER PAGE

FOR HRSA USE ONLY

Grantee Name

Grant Number

Application Tracking #

1. Purpose

Explain how the FIP proposal will appropriately address your community’s immediate needs and how it will enhance the health center’s effectiveness, efficiency, quality of care, and patient outcomes. Describe how the FIP proposal will promote economic recovery. Provide an overview and justification for the FIP proposal, including goals and objectives. (Maximum 2000 characters) (Note: Please include Proposal Abstract with this application)

2. Sustainability Plan

Describe the overarching impact of the FIP proposal on the operational budget and how the proposal will impact your organization and promote organizational sustainability once the project has been completed. This plan should outline how the health center will support operating costs of including utilities, maintenance, repair, and capital reinvestment costs for the proposed project(s). Explain how the center will maintain the improved access/services resulting from the FIP project(s) within its existing operational budget/grant support in the long-term---applicants must demonstrate that no ongoing section 330 support is required. FIP grant funds cannot be used to support direct-service providers. If appropriate, describe how the organization will pay or retire the capital debt related to the FIP proposal.(Maximum 2000 characters)

3. Green/Sustainable Design Principles

Please describe how you will reduce the project’s potential adverse impacts on the environment. Indicate whether or not the health center will implement green/sustainable design practices for this proposal. Explain how the health center will be implementing green/sustainable principles (e.g., using project materials, construction approaches, equipment selection). (Maximum 2000 characters)

[_] Yes [_] No

If ‘Yes’, please provide explaination

4. Service Impacts

As a result of the FIP grant, health centers should be able to project impacts of this funding on the health center’s service delivery. Projections should reflect expected levels upon completion of all projects in the proposal.

Projected number of additional health center service provider FTEs (medical, dental, behavioral health, pharmacy, other professional, and enabling)
Total number of additional patients served
Total number of additional visits

5. Financial Management and Control

5a. Describe the health center’s financial management and control policies and procedures. (Maximum 2000 characters)

5b. Provide the following indicators over the past 3 years: net assets, debt/equity ratio, and working capital

Indicator	FY 2006	FY 2007	FY 2008
Net Assets
Debt/Equity Ratio
Working Capital	$	$	$