Form 1A General Information Worksheet

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FORM 1A: GENERAL INFORMATION WORKSHEET

FOR HRSA USE ONLY

Application Tracking Number

Grant Number

 

1. Applicant Information

Applicant Name

 

Fiscal Year End Date

Application Type

 

Existing Grantee

 

Grant Number

 

BHCMIS ID

 

Business Entity

(Select one)

[_] Tribal

[_] Urban Indian

 [_] Private, non-profit (non-Tribal or Urban Indian)

 [_] Public (non-Tribal or Urban Indian)

Organization Type

(Select all that apply)

 [_] Faith based
 [_] Hospital
 [_] State government

[_] City/County/Local Government or Municipality

 [_] University

 [_] Community based organization

[_] Other - Specify: __________

2. Proposed Service Area

Applicants applying for Community Health Center (CHC) funding in Section A of the SF-424A: Budget Information form must serve at least one MUA or MUP. Provide the IDs for all MUAs and/or MUPs within the service area proposed in this application.provide at least one designated service area ID under an MUA or MUP.

2a. Target Population and Service Area Designation Select MUA/MUP

(Each ID must be a 5 digit integer. Use commas to separate multiple IDs.)

(Use commas to separate multiple IDs)

Find an MUA/MUP

Select one or more population types:

 [_] Serving Section 330(e) - Community Health Centers

[_] Serving Section 330(g) - Migrant Health Centers
 [_] Serving Section 330(h) - Homeless Health Centers
 [_] Serving Section 330(i) - Public Housing Health Centers

Select one or more MUA/MUP options, as applicable:

 [_] Medically Underserved Area (MUA): ID#____
 [_] Medically Underserved Population (MUP): ID#____
 [_] MUA Application Pending: ID#____
 [_] MUP Application Pending: ID#____

2b. Service Area Type

(Choose Service Area Type)

 [_] Urban
 [_] Rural

[_] Sparsely Populated - Specify population density by providing the number of people per square mile: ____________

(Provide a value ranging from 0.01 to 7.)

2c. Target Population and Provider InformationPatients and Visits	Current Number	Projected at End of Project Period
Total Service Area Population
Total Target Population
Total FTE Medical Providers
Total FTE Dental Providers
Total FTE Behavioral Health Providers
Total FTE Substance Abuse Service Providers
Total FTE Enabling Service Providers

Patients and Visits by Service Type
Service Type Current Number Projected at End of Project Period
		Patients			Visits					Patients		Visits
Total Medical Services
Total Dental Services
Total Behavioral Health
Total Mental Health Services
Total Substance Abuse
Total Enabling Services
Unduplicated Patients and Visits by Population Type
Patient Projection: How many unduplicated patients are projected to be served by December 31, 2018?
Population Type	Current Number (b)UDS/Baseline Value			Number at End of Year 1 (b)			Number After Year 2 (c)		Projected by December 31, 2018 (January 1 – December 31, 2018)Number at End of Project Period (d)
	Patients		Visits	Patients		Visits	Patients	Visits	Patients		Visits
TOTAL
General Underserved Community (Includes all patients/visits not reported in the rows below.)
Migratory andnt /Seasonal Farm Agricultural Workers and Families
Public Housing Residents
Homeless PersonsPeople Experiencing Homelessness
TOTAL
Patients and Visits by Service Type
Service Type		UDS/Baseline Value								Projected by December 31, 2018 (January 1 – December 31, 2018)
		Patients			Visits					Patients		Visits
Total Medical Services
Total Dental Services
Total Behavioral Health
Total Mental Health Services
Total Substance Abuse
Total Enabling Services

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 14N-3910-33, Rockville, Maryland, 20857.