8 Health Center Agreements Final

Form 8 – Health Center Agreements
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 8: HEALTH CENTER AGREEMENTS

Application
Tracking Number

Note: When a health center award recipient wishes to establish an agreement/arrangement in the future that
will either (1) result in another organization carrying out a substantial portion of the approved scope of
project or (2) impact the governing board’s composition, authorities, functions, or responsibilities, a Prior
Approval request must be submitted in EHB and approved by HRSA before the agreement/arrangement can
be formalized and implemented.
PART I Health Center Agreements
1. Does your organization have a parent, affiliate, or subsidiary organization?
2. Do you have, or propose to make as part of this application any subawards to
subrecipients and/or will you contract with another organization to carry out a substantial
portion of the proposed scope of project? Contracts for a substantial portion of the award
include contracting for the majority of core primary care services, and/or contracting for the
Chief Executive Officer (CEO), and/or the entire key management team inclusive of the
CEO.
NOTE:
•

Subawards or contracts made to related organizations such as a parent, affiliate,
or subsidiary must be addressed in this form.

[_]Yes [_] No

[_]Yes [_] No

This form excludes contracts for the acquisition of supplies, material, equipment,
or general support services (e.g., janitorial services, contracts with individual
providers).
If Yes, indicate the number of each agreement by type in 2a and/or 2b below and complete
Part II. If No, Part II is Not Applicable.
•

2a. Number of contracts for a substantial portion of the proposed scope of project for any of
the following: the majority of core primary care services and/or contracting for the
CEO and/or the entire key management team inclusive of the CEO.

___ (number)

2b. Number of subrecipients that will carry out a substantial portion of the proposed scope of
project via a subaward.

___ (number)

2c. Total number of contracts and/or subawards for a substantial portion of the proposed
scope of project.

___ (number)

Part II: Attachments
All affiliations/contracts/subawards referenced in Part I must be uploaded in full. Uploaded documents will
NOT count against the page limit.
Affiliate/Contract/Subaward Organization Name
(maximum 50 characters)
Type of Agreement

[_] Affiliation Agreement
[_] Subaward
[_] Contract

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 45 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.

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