Form 1 Other Requirements for Sites

The Health Center Program Application Forms

26. Other requirement for sites

Other Requirements for Sites

OMB: 0915-0285

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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

  1. any renovation/modification to the exterior of the facility (including the installation of new signage), or



  1. 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



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSBHCC Forms in WORD Format
AuthorKinny Padh
File Modified0000-00-00
File Created2021-01-28

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