DEPARTMENT OF HEALTH AND HUMAN SERVICES

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DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Health Resources and Services Administration 

CHECKLIST FOR RELOCATING A SITE (CHKLST005) 
Grantee Name: 

Grantee Number: 

CIS Tracking Number: 


Questions for Relocation of Service Site 
From Site(s) 
Site has not been selected.
To Site(s) 
Site has not been selected.
*1. 
Describe the reason for the relocation and how it will benefit the total level or quality of health services provided to the target population?
(Please provide a summary of one page or less.) 


(maximum 3,000 characters)
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)


*2. Is the relocation temporary or permanent?

Permanent
Temporary



*2a. 
When do you plan to relocate the site(s)?





Effective date for site relocation (mm/dd/yyyy): 




*3. Information about the impact of the relocation of service site on the area currently served

3a. Will the relocation cause a change in zip code(s) for your service area?


Yes
No



3b. If yes to 3a, describe the change in the space provided below:


(maximum 3,000 characters)
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)


*4. Will the majority of patients have to travel further to access care at the new address?

Yes
No



4a. If yes, what is the additional distance patients will have to travel to the site, on average?


Distance:  miles (Format: 9 or 9.99)

Time:       hrs   mins  (Format: 99)


4b. If yes, will transportation services be available?


Yes
No
Not Applicable



4c. If yes, how far is the new site location from your current site?


Distance: 
  miles (Format: 9 or 9.99)


Travel Time: 
  hrs   mins  (Format: 99)



4d. 
If yes, describe how you will address any barriers that the new location may present. (Please provide a summary of one page or less.) 



(maximum 3,000 characters)
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)


*5. Is the new address of the site within your current service area? 

Yes
No



5a. If No, are there other health centers (funded FQHCs or FQHC Look-Alikes) near the new address?


Yes
No
Not Applicable



5b.
If Yes to 5a, identify below, and provide a letter of cooperation and support from the neighboring health centers if available.
Final action cannot be taken on your Change in Scope (CIS) request without careful consideration of the impact of this site on the operation of neighboring health centers.


To upload supporting attachments, visit the 'Supporting Documents' section in this CIS Request. 

Name and address of neighboring health centers 

(maximum 3,000 characters)
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)


*6. Information comparing the current site and site at new address through the First Year after the relocation. 

6a. Number of patients served at the service site


Current Service Site: (Format: 99)
Service Site at new address: (Format: 99)


6b. Number of providers


Current Service Site: (Format: 99)
Service Site at new address: (Format: 99)


6c. Square footage


Current Service Site: (Format: 9 or 9.99)
Service Site at new address: (Format: 9 or 9.99)


6d. Rent or lease cost


Current Service Site: (Format: 9 or 9.99)
Service Site at new address: (Format: 9 or 9.99)


6e. Maintenance costs


Current Service Site: (Format: 9 or 9.99)
Service Site at new address: (Format: 9 or 9.99)


6f. Total expenses


Current Service Site: (Format: 9 or 9.99)
Service Site at new address: (Format: 9 or 9.99)

*7. 
Does the information above indicate that the expenses of operating the relocated site exceed the expenses of the original site by 20% or more?


Yes
No



7a.
If Yes, submit Form 3: Income Analysis, showing the projected number of encounters, payer mix, revenue projections, and other sources of support for the relocated site specific for one year only. 


If Form 3: Income Analysis Format, demonstrate that additional funds will be necessary to support the relocated site, the grantee must provide specific budgetary information demonstrating how the increased expenses are to be covered. 

(Additional documents can be provided in the Other Information - Supporting Documents section of the Grantee Handbook.) 


7b.
Does the information provided in Form 3: Income Analysis indicate that the projected revenue from operating the site will be adequate to support the activities at the new site address?


Yes
No
Not Applicable


*8. 
Does your Board of Directors currently have representation from the area of the newly proposed site?


Yes
No
Not Applicable



8a.
If No, describe how you plan to obtain Board representation from the new area?


(maximum 3,000 characters)
Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)