Form 1 Other Requirements for Sites

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration OTHER REQUIREMENTS FOR SITES	FOR HRSA USE ONLY
	Application Tracking Number			Grant Number
	Project Number			Project Type
	Project Title
1. Site Control and Federal Interest
Identify current status of property (If ‘Leased’, please provide Landlord Letter of Consent)
[_]Owned by the applicant [_] Leased/Occupancy Agreement
2. Cultural Resource and Historic Preservation Considerations (For Alteration/Renovation (A&R) projects ONLY)
2a. Is the project facility 50 years or older?			[_] Yes [_] No
2b. Does the overall proposed project include any renovation/modification to the exterior of the facility (including the installation of new signage), or ground disturbance activities (including installation of permanent access ramps, utility work, installation of curb cuts, fencing, and parking)?			[_] Yes [_] No
2c. Does the project involve renovation to a facility or site that is historically, culturally, or architecturally significant?			[_] Yes [_] No
2d. Is the site located on current or historic Native American, Alaskan Native, Native Hawaiian, or equivalent, culturally significant land?			[_] Yes [_] No
Landlord Letter of Consent (Maximum 1 attachment)
If property status is ‘Leased’ please provide Landlord Letter of Consent.
Property Information (Maximum 1 attachment)
If property status is ‘Leased’ or ‘Owned’ please provide Property Information