Form 4 Community Characteristics

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 4: COMMUNITY CHARACTERISTICS		FOR HRSA USE ONLY
		Grant Number			Application Tracking Number
	CHARACTERISTIC		SERVICE AREA DATA			TARGET POPULATION DATA
			#	%		#	%
RACE	Native Hawaiian
	Other Pacific Islander
	Asian
	Black/African American
	American Indian/Alaskan Native
	White
	More than One Race
	Unreported/Refused to Report (if applicable)
	Total:			100%			100%
HISPANIC OR LATINO IDENTITY	Hispanic or Latino
	Non-Hispanic or Latino
	Unreported/Refused to Report (if applicable)
	Total:			100%			100%
INCOME AS A PERCENT OF POVERTY LEVEL	Below 100%
	100-199%
	200% and Above
	Unknown
	Total:			100%			100%
PRIMARY THIRD PARTY PAYMENT SOURCE	Medicaid
	Medicare
	Other Public Insurance
	Private Insurance, Including Capitation
	None/Uninsured
	Total:			100%			100%
SPECIAL POPULATIONS	Migrant/Seasonal Farm Workers and Families
	Homeless
	Residents of Public Housing
	Lesbian, Gay, Bisexual, and Transgender
	HIV/AIDS-Infected Persons
	Persons with Behavioral Health/Substance Abuse Needs
	School Age Children
	Infants Birth to 2 Years of Age
	Women Age 25-44
	Persons Age 65 and Older
	Other Please Specify:______________

Note: When completing Form 4 – Community Characteristics – please note that all information provided regarding race and/or ethnicity will be used only to ensure compliance with statutory and regulatory Governing Board requirements.  Data on race and/or ethnicity collected on this form will not be used as an awarding factor.

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.