Form 5C Other Activities/Locations

OMB No.: 0915-0285. Expiration Date: xx/xx/xxxx 9/30/2016

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Form 5C: OTHER ACTIVITIES/LOCATIONS		FOR HRSA USE ONLY
		Grant Number	Application Tracking Number
Note: For current grantees, the system will pre-populate this form.
Activity/Location Information
Type of Activity (select one)	[_] Immunizations [_] Hospital Admitting [_] Medical Rounds [_] Home Visits [_] Health Fairs [_] Non-Clinical Outreach [_] Portable Clinical Care [_] Health Education [_] Other – Please Specify:
Frequency of Activity
Description of Activity
Type of Location(s) where Activity is Conducted

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-3910-29, Rockville, Maryland, 20857