6B Request for Waiver of Board Member Final

Form 6B: Request for Waiver of Board Member Requirements
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

FORM 6B: REQUEST FOR WAIVER OF BOARD
MEMBER REQUIREMENTS

Application Tracking
Number

Note: This form is applicable if you are proposing to serve only special populations (i.e., HCH,MHC, and/or PHPC)
Request for Waiver
Name of Organization

Will pre-populate in EHB

1. New Waiver Request
Are you requesting a new waiver of the 51% patient majority
governance requirement?

[_] Yes [_] No

2. For Applicants with Previous Waiver
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?
(This question is required if you answered yes to question 2a.)

[_] Yes [_] No (Governing board is in full
compliance)

3. Demonstration of Good Cause for Waiver
(Demonstrate good cause for the waiver request by addressing the following areas)
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
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)
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-39, Rockville, Maryland, 20857.

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