Form 1C Documents on File

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 1C: DOCUMENTS ON FILE	FOR HRSA USE ONLY
	Grant Number		Application Tracking Number
Note: Example date formats for use on this form are 01/15/2016, First Monday of every April, and bi-monthly (last rev 01/16).
NEED Need		DATE OF LATEST REVIEW/REVISION Date of Latest Review/Revision (maximum 100 characters)
Needs Assessment (Program Requirement 1)
MANAGEMENT AND FINANCE Management and Finance		DATE OF LATEST REVIEW/REVISION Date of Latest Review/Revision (maximum 100 charaters)
Personnel Policies and/or Procedures, including related Conflict of Interest Policies and ProceduresProvisions (Program Requirements 3, 9, 17, and 19)
Data Collection and ConfidentialityManagement Information Systems (Clinical and Financial) Policies and/or Procedures (Program Requirements 8 and 15)
Billing, Credit, and Collection Policies and/or Procedures and Schedule of Fees for Services (Program Requirement 13 and Policy Information Notice 2014-02 – http://bphc.hrsa.gov/programrequirements/policies/pin201402.html)
Procurement Policies and/or Procedures, including related Conflict of Interest Provisions Policies and Procedures (Program Requirements 10, 12, and 19 and Uniform Guidance 2 CFR 200 as codified by HHS at 45 CFR 75)
Emergency Preparedness and Management Plan (Policy Information Notice 2007-15 – http://bphc.hrsa.gov/about/pin200715expectations.html)
Fee Schedule/Schedule of Charges (Program Requirements 7 and 13)
Sliding Fee Discount Program Policies and Procedures (Program Requirement 7)
Financial Management/Accounting and Internal Control Policies and/or Procedures (Program Requirements 10 and 12 and Policy Information Notice 2013-01 – http://bphc.hrsa.gov/programrequirements/policies/pin201301.html)
Contracts and/or Subrecipient Agreements, as applicable (Program Requirement 10)
SERVICESServices		DATE OF LATEST REVIEW/REVISION Date of Latest Review/Revision (maximum 100 charaters)
Sliding Fee Discount Program Policies and/or Procedures (Program Requirement 7 and Policy Information Notice 2014-02 – http://bphc.hrsa.gov/programrequirements/policies/pin201402.html)
HIPPA-Compliant Patient Confidentiality Policies and Procedures (Program Requirement 8)
Clinical Protocols/Clinical Care Policies and/or Procedures (Program Requirements 2, 6, and 8)
Patient Grievance Policies and/or Procedures (Program Requirements 8 and 17)
Quality Improvement and Quality Assurance Plan, including Incident Reporting System and Risk Management Policies and/or Procedures (Program Requirement 8)
Malpractice Coverage Plan—e.g., Includes FTCA Coverage for deemed grantees award recipients or other malpractice coverage (Program Requirement 8 and Policy Information Notice 2011-01: (FTCA Health Center Policy Manual – http://bphc.hrsa.gov/ftca/healthcenters/ftcahcpolicymanual.html)
Credentialing and Privileging Policies and/or Procedures (Program Requirement 3 and Policy Information Notices 2001-16 – http://bphc.hrsa.gov/programrequirements/policies/pin200116.html and 2002-22 – http://bphc.hrsa.gov/programrequirements/policies/pin200222.htmland 2002-22)
After-Hours Coverage Policies and/or Procedures (Program Requirements 4 and 5)
Hospital Admitting Privileges Documentation and/or Arrangements (Program Requirement 6)
GOVERNANCEGovernance		DATE OF LATEST REVIEW/REVISION Date of Latest Review/Revision (maximum 100 charaters)
Organizational/Board Bylaws, including board member Conflict of Interest Provisions for Board MembersPolicies and Procedures (Program Requirements 17, 18, and 19 and Policy Information Notice 2014-01 – http://bphc.hrsa.gov/programrequirements/policies/pin201401.html)
Co-Applicant Agreement, if a public organization agency (Program Requirement 17 and Policy Information Notice 2014-01 – http://bphc.hrsa.gov/programrequirements/policies/pin201401.html)

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 hour30 minutes 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.