Form 6a Current Board Member Characteristics

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 6A: CURRENT BOARD MEMBER CHARACTERISTICS			FOR HRSA USE ONLY
			Grant Number				Application Tracking Number
BOARD MEMBER NAME	BOARD OFFICE HELD	AREA OF EXPERTISE (Place asterisk (*) if member derives more than 10% of income from health industry)		>10% of income from health industry	HEALTH CENTER PATIENT	LIVE OR WORK IN SERVICE AREA		YEARS OF CONTINUOUS BOARD SERVICE	SPECIAL POPULATION REPRESENTATIVE (If yes, specify Special Population)

Gender	Number of Board Members
Male
Female
Unreported/Refused to Report
Ethnicity	Number of Board Members
Hispanic or Latino
Non-Hispanic or Latino
Unreported/Refused to Report
Race	Number of Board Members
Native Hawaiian
Other Pacific Islander
Asian
Black/African American
American Indian/Alaska Native
White
More Than One Race
Unreported/Refused to Report

Note: Add additional pages if needed.

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.