Form 1 Proposal Cover Page

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

PROPOSAL COVER PAGE

FOR HRSA USE ONLY

Application Tracking #

Grant Number

1. Applicant Eligibility

Is the applicant organization currently an existing health center under the Section 330 Program?

^{(If ‘Yes’ please provide the H80 grant number below.)}

[_] Yes [_] No

H80 Grant Number (Example: H80CS00001)

2. Need

Describe the existing state of the facility. Describe how the facility deficiencies have impacted the ability to adequately staff and operate the health center. Indicate whether or not the proposed project has started construction activities and/or issued a construction contract. Provide a justification for the equipment requested and its appropriateness with the facility improvement(s).

(Maximum 8000 characters)

3. Response

Indicate how the health center will support operating costs, including increases in utilities, daily maintenance and repair, and capital reinvestment for the identified project(s). Explain how the health center will maintain the facility improvements resulting from the project(s) within its existing operational budget—applicants must demonstrate that no ongoing section 330 support is required. If appropriate, describe how the organization will pay or retire the capital debt related to the proposal. Provide evidence of support from the community, stakeholders, and patient population.

(Maximum 4000 characters)

4. Service Impacts

Describe how the proposed project(s) will enhance the quality of care and patient outcomes, and improve access to care within the community. Describe how the proposed project(s) will promote the sustainability of the services provided by the health center once the project has been completed.

(Maximum 4000 characters)

5. Resources/Capabilities

Describe how the health center has the appropriate resources and capabilities to successfully implement and complete the proposed project(s) (e.g., prior experience, project management capabilities). Identify the health center’s acquisition strategy, policies, and procedures, and how the project(s) will comply with Federal procurement requirements. Explain how the applicant organization will ensure the project(s) will be completed on time (within the 2-year project period) and within budget (e.g., role of the board, management team, project team).

(Maximum 4000 characters)

6. Funding Priority

Attached Document (Maximum 1 attachment)
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