Form 6B Request for Waiver of Board Member

OMB No.: 0915-0285. Expiration Date: xx/xx/xxxx 10/31/2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 6B: REQUEST FOR WAIVER OF GOVERNANCE BOARD MEMBER REQUIREMENTS		FOR HRSA USE ONLY
		Application Tracking Number Grant Number	Grant NumberApplication Tracking Number
Note: This form is only applicable if you are proposing to serve only special populations (i.e., HCH, MCH, and/or PHPC)
1. Request for Waiver
Name of Organization	Will pre-populate in EHB
1. New Waiver Request
1a. Are you requesting a new waiver of the 51% patient majority governance requirements?	[_] Yes [_] No  [_] Not Applicable
2. For Applicants with Previous Waiver
2a. Nature of Items Currently Approved to be Waived	[_] 51 Percent Patient Majority [_] Monthly Meetings
2a. Do you currently have a waiver of the 51% patient majority governance requirement?	[_] Yes [_] No
2b. Are you requesting the patient majority waiver to be continued? (Answer to tThis question is mandatory required if you answered yes to Question question 2a.)	[_] Yes (Complete Next Question) [_] No (Governing Board is in Full Compliance)
2c. Is your waiver request based on arrangements that are different from your original request? (Answer to this question is mandatory if you answered Yes to Question 2b.)	[_] Yes [_] No
3. Demonstration of Good Cause for Waiver New Waiver Request (Demonstrate good cause for the waiver request by addressing the following areas)
3a. Nature of Items for New Waiver Request (Answer to this question is mandatory if you answered Yes to Question 1a.)	[_] 51 Percent Patient Majority [_] Monthly Meetings
3a. Provide a description of the population to be served and the characteristics of the population/service area that would necessitate a waiver. (This question is required if you answered ‘Yes’ to question 1 and/or question 2b.) (maximum 1,000 characters)
3b. Provide a description of the health center’s attempts to meet the requirement to date and explain why these attempts have not been successful. (This question is required if you answered ‘Yes’ to question 1 and/or question 2b.) (maximum 1,000 characters)
4. Alternative Mechanism Plan for Addressing Patient Representation All Organizations Requesting Waiver: Describe the appropriate alternative strategies in place that will assure consumer/patient participation and/or regular oversight in the direction and ongoing governance of the organization.
4a. Strategy 1 (Answer to this question is mandatory if you answered Yes to Question 1a.) Present a plan for complying with the intent of the statute via an alternative mechanism that ensures patient input and participation in the organization, as well as direction and ongoing governance of the health center. (This question is required if you answered ‘Yes’ to question 1 and/or question 2b.) (maximum 1,000 characters)
4b. Strategy 2
4c. Other Strategies

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.

Instructions

• An applicant that currently receives or is applying to receive CHC (section 330(e)) funding is not eligible for a waiver and cannot enter information.

• Indian tribes or tribal, Indian, or urban Indian groups are not required to complete this form and cannot enter information.

• Competing continuation applicants that wish to continue an existing waiver must complete this form.

• When requesting a waiver, briefly demonstrate good cause as to why the patient majority board composition requirement cannot be met, and present a plan for ensuring patient input and participation in the organization, direction, and ongoing governance of the health center. The plan must provide all of the following:

  • Clear description of the alternative mechanism(s) for gathering patient input. If advisory councils or patient representatives are proposed, include a list of the members in Attachment 14: Other Relevant Documents that identifies these individuals and their reasons/qualifications for participation on the advisory council or as governing board representatives.

  • Specifics on the type of patient input to be collected.

  • Methods for collecting and documenting such input.

  • Process for formally communicating the input directly to the health center governing board (e.g., monthly presentations of the advisory group to the full board, monthly summary reports from patient surveys).

  • Specifics on how the patient input will be used by the governing board for: 1) selecting health center services; 2) setting health center operating hours; 3) defining budget priorities; 4) evaluating the organization’s progress in meeting goals, including patient satisfaction; and 5) other relevant areas of governance that require and benefit from patient input.