5C Other Activities/Locations Final

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FOR HRSA USE ONLY

Grant Number

Application
Tracking Number

Form 5C: OTHER ACTIVITIES/LOCATIONS
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 30 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-39,
Rockville, Maryland, 20857.