Form 5a Services Provided

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 5A: SERVICES PROVIDED	FOR HRSA USE ONLY
	Application Tracking Number		Grant Number
SERVICE TYPE	MODE OF SERVICE PROVISION
	DIRECT BY APPLICANT	FORMAL WRITTEN CONTRACT/AGREEMENT (Applicant pays for service)		FORMAL WRITTEN REFERRAL ARRANGEMENT/AGREEMENT (Applicant DOES NOT pay)
Required Services
Clinical Services
General Primary Medical Care
Diagnostic Laboratory
Diagnostic X-Ray
Screenings
Cancer
Communicable Diseases
Cholesterol
Blood Lead Test for Elevated Blood Lead Level
Pediatric Vision, Hearing, and Dental
Emergency Medical Services
Voluntary Family Planning
Immunizations
Well Child Services
Gynecological Care
Obstetrical Care
Prenatal and Perinatal Services
Preventive Dental
Referral to Behavioral Health1
Referral to Substance Abuse1
Referral to Specialty Services
Pharmacy
Substance Abuse Services (Required for HCH Programs):
Detoxification
Outpatient Treatment
Residential Treatment
Rehabilitation (Non-Hospital Settings)
Non-Clinical Services
Case Management
Counseling/Assessment
Referral
Follow-Up/Discharge Planning
Eligibility Assistance
Health Education
Outreach
Transportation
Translation
Substance Abuse Services (Required for HCH Programs):
Harm/Risk Reduction (e.g., nicotine gum/patches, educational materials)
Additional Services (Optional)
Clinical Services
Urgent Medical Care
Dental Services
Restorative
Emergency
Behavioral Health Services
Treatment/Counseling
Developmental Screening
24-Hour Crisis
Substance Abuse Services
Comprehensive Eye Exams and Vision Services
Recuperative Care
Environmental Health Services
Occupational-Related Health Services2
Screening for Infectious Diseases
Injury Prevention Programs
Occupational Therapy
Physical Therapy
HIV Testing
TB Therapy
Hepatitis C
Screening
Therapy/Treatment
Podiatry
Rehabilitation (Non-Hospital Settings)
Specialty (Please Specify: ____________)
Other (Please Specify: _______________)
Non-Clinical Services
WIC
Nutrition (not WIC)
Child Care
Housing Assistance
Employment and Education Counseling
Food Bank/Meals
Specialty (Please Specify: ____________)
Other (Please Specify: _______________)

1. Applicants are required to provide behavioral health and substance abuse services by referral arrangements. However, applicants may provide these services by applicant or formal agreement in addition to by referral arrangements by indicating these services under additional services.

2. Additional Services for Health Centers serving Migrant and Seasonal Farm Workers (MSFWs).

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 .5 hours 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.