Form Instructions

FORM 1A – General Information Worksheet (Required)

Form 1A provides a summary of information related to the proposed NAP project, including specific applicant information, the proposed service area, target population, service type, current and projected patient and visits, and applicable funding factors.  The following instructions are intended to clarify the information to be reported in each section of the form.

• Applicants with more than one proposed new access point should report aggregate data for all of the sites included in the proposed NAP application.

• New start applicants proposing one or more new access points should report combined data for all of the sites to be included under the scope of project. 

• Satellite applicants should provide data for the proposed NEW ACCESS POINT(S) ONLY. 

• “Current” refers to the number of patients and/or visits served by the organization at the time of application.  “Projected at the End of the Project Period” refers to the number of patients and/or visits by the new access point(s) at the end of the two year project period. 

• If a new access point(s) is already operational, report the current number of patients/visits, as well as the projected number of patients and visits after 2 years of operation.  If the new access point (s) is not operational, report current number as “0”. 

• Applicants that were awarded section 330 funding for the first time under the Recovery Act are considered to be an existing section 330 grantee and may apply as a satellite applicant for HRSA-11-017.

1. APPLICANT INFORMATION

• Complete all relevant information that is not automatically pre-populated.  Note that Grant and UDS Numbers are ONLY applicable for satellite applicants.    

• Applicants may check only one category in the Business Entity section.  If an applicant is a Tribal or Urban Indian entity and also meets the definition for a public or private entity, then the Applicant should select the Tribal or Urban Indian category only. 

• Applicants may select more than one category for the Organization Type section.

2. PROPOSED SERVICE AREA:

2a. Service Area Designation:  

• Select the designation(s) which best describe the proposed service area.  Multiple selections are allowed.  For inquiries regarding Medically Underserved Areas or Medically Underserved Populations, please call 1-888-275-4772. Press option 1, then option 2 or contact the Shortage Designation Branch via email [email protected] or 301-594-0816. For additional information, visit the HRSA Bureau of Health Professions Shortage Designation website at http://bhpr.hrsa.gov/shortage/.

• Select the type of funding requested (i.e., section 330(e), section 330(g), section 330(h), and/or section 330(i)).

2b. Target Population Type: Classify the proposed target population type as Rural or Urban.

2c. Target Population and Provider Information:  For all portions of this section, applicants with more than one proposed new access point should report aggregate data for all of the sites included in the proposed project.

Target Population Information:

• Provide the estimated number of individuals currently composing the service area and target population.

Provider FTEs by Type:

• Provide a count of Billable Provider FTEs ONLY (e.g., physician, nurse practitioner, physician assistant, certified nurse midwife, psychiatrist, psychologist, dentist).

• “Projected at the End of the Project Period” refers to the number of FTEs as a result of the NAP application at the end of the two year project period. 

• Do not report provider FTEs outside the organization’s proposed scope of project.

Patients and Visits by Service Type:

• “Projected at End of the Project Period” refers to the number of patients and/or visits anticipated as a result of the NAP application at the end of the project period. 

• Do not report patients and visits for services outside the organization’s proposed scope of project.

• Data reported for patients and visits should not be duplicated WITHIN each of the four categories (i.e., Medical, Dental, Mental Health, and Substance Abuse).  Within each category, an individual can only be counted once as a patient.  However, an individual who receives multiple types of services should be counted as a patient for EACH service type for which services were rendered (i.e., data reported for patients and visits should be duplicated ACROSS each of the four categories).  For example, if an individual is a patient receiving both mental health and dental services, then this individual would be recorded as a patient (and encounter) in both the mental health and dental categories.  Note: Please use the following guidelines when providing data regarding patients and visits:

1. Visits are defined to include a documented, face-to-face contact between a patient and a provider who exercises independent judgment in the provision of services to the individual. To be included as a visit, services rendered must be documented in the patient’s record.

2. Patients are defined to include an individual who had at least one visit in the previous year.

3. Since patients must have at least one documented visit, it is not possible for the number of patients to exceed the number of visits.

Patients and Visits by Population Type:

• “Projected at End of the Project Period” refers to the number of patients and/or visits anticipated as a result of the NAP application at the end of the project period.

• Do not report patients and visits for services outside the organization’s proposed scope of project.

• Data reported for patients and visits should not be duplicated WITHIN or ACROSS the four Target Population Categories (i.e., General Community, Migrant/Seasonal Farm Workers, Public Housing Residents, Homeless Persons).  Please use the guidelines a-c above when providing data regarding patients and visits.  Note that Population Type in this table refers to the population being served, not the Funding Type (i.e., section 330(g), section 330(h), section 330(i)).

3.  FUNDING PRIORITIES

Sparsely Populated Rural Areas (5 points, see section V.2, Review and Selection Process).  Applicants requesting consideration of a Funding Priority must indicate the request on FORM 1-A and provide documentation (e.g., information from the Census Bureau) indicating that the entire area to be served has seven (7) or less people per square mile.  Data should be presented at the census tract and/or zip code level.

High Poverty Application (up to 5 points; see section V.2, Review and Selection Process). Applicants requesting consideration of a Funding Priority must indicate the request on FORM 1-A and provide documentation (e.g., information from the Census Bureau) indicating that the Percent of Population at or below 100% of poverty exceeds 30 percent in the entire service area to be served by the proposed project.  Data should be presented at the census tract and/or zip code level.

Special Population Application (up to 10 points, see section V.2, Review and Selection Process).  Applicants requesting consideration of a Funding Priority must indicate the request on FORM 1-A and demonstrate on Form 1B a request for special population(s) funding (section 330(i), section 330(h), and/or section 330(g)) that is at least 25 percent of the total requested section 330 funds..