Form 1 General Information Worksheet

OMB No.: 0915-0285. Expiration Date: 10/31/2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FORM 1A: GENERAL INFORMATION WORKSHEET

FOR HRSA USE ONLY

Application Tracking Number

Grant Number

 

1. Applicant Information

Applicant Name

 

Fiscal Year End Date

Application Type

 

Existing Grantee

 

Grant Number

 

BHCMIS ID

 

Business Entity

[_] Tribal

[_] Urban Indian

 [_] Private, non-profit (non-Tribal or Urban Indian)

 [_] Public (non-Tribal or Urban Indian)

Organization Type

 [_] Faith based
 [_] Hospital
 [_] State government

[_] City/County/Local Government or Municipality

 [_] University

 [_] Community based organization

[_] Other - Specify: __________

2. Proposed Service Area

Applicants applying for Community Health funding must provide at least one designated service area ID under an MUA or MUP.

2a. Target Population and Service Area Designation

(Use commas to separate multiple IDs)

Find an MUA/MUP

Select one or more population types:

 [_] Serving Section 330(e) - Community Health Centers

[_] Serving Section 330(g) - Migrant Health Centers
 [_] Serving Section 330(h) - Homeless Health Centers
 [_] Serving Section 330(i) - Public Housing Health Centers

Select one or more MUA/MUP options, as applicable:

 [_] Medically Underserved Area (MUA): ID#____
 [_] Medically Underserved Population (MUP): ID#____
 [_] MUA Application Pending: ID#____
 [_] MUP Application Pending: ID#____

2b. Service Area Type

 [_] Urban
 [_] Rural

[_] Sparsely Populated - Specify population density by providing the number of people per square mile: ____________

2c. Target Population and Provider Information	Current Number	Projected at End of Project Period
Total Service Area Population
Total Target Population
Total FTE Medical Providers
Total FTE Dental Providers
Total FTE Behavioral Health Providers
Total FTE Substance Abuse Service Providers
Total FTE Enabling Service Providers

Patients and Visits by Service Type
Service Type		Current Number						Projected at End of Project Period
		Patients			Visits			Patients				Visits
Total Medical
Total Dental
Total Behavioral Health
Total Substance Abuse
Total Enabling Services
Patients and Visits by Population Type
Population Type	Current Number (b)			Number at End of Year 1 (b)			Number After Year 2 (c)			Number at End of Project Period (d)
	Patients		Visits	Patients		Visits	Patients		Visits		Patients		Visits
General Community
Migrant/Seasonal Farm Workers
Public Housing Residents
Homeless Persons
TOTAL

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.