Form 6A Current Board Member Characteristics

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 6A: CURRENT BOARD MEMBER CHARACTERISTICS				FOR HRSA USE ONLY
				Grant Number			Application Tracking Number
Note: This form will pre-populate for competing continuation and competing supplement applicants.
BOARD MEMBER Name	Current Board Office Position Held	Area of Expertise (Place asterisk (*) if member derives more than 10% of income from health industry)	>10% of Income from Health Industry		Health Center Patient	Live or Work in Service Area	Special Population Representative (If yes, specify Special Population)
PATIENT BOARD MEMBER CLASSIFICATION

Gender	Number of Patient Board Members
Male
Female
Unreported/RefusDeclined to Report
Ethnicity	Number of Patient Board Members
Hispanic or Latino
Non-Hispanic or Latino
Unreported/RefusDeclined to Report
Race	Number of Patient Board Members
Native Hawaiian
Other Pacific Islanders
Asian
Black/African American
American Indian/Alaska Native
White
More Than One Race
Unreported/RefusDeclined to Report

Note: The question below is ONLY required if you selected Public (non-Tribal or Urban Indian) as the Business Entity on Form 1A of this application. In all other cases, select N/A.

If the applicant is a public organization/center, do the board members listed above represent a co-applicant

board? Yes [ ] No [ ] N/A [ ]

If yes, ensure that the co-applicant agreement is included as Attachment 6 in the Appendices form of this application.

Note: Add additional pages if needed.

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 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 10-3314N-39, Rockville, Maryland, 20857.