9 Need for Assistance Worksheet Final

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Form 9: NEED FOR ASSISTANCE WORKSHEET	FOR HRSA USE ONLY
	Grant Number	Application Tracking Number
Section I: CORE BARRIERS Note: Provide information for 3 out of the 4 Core Barriers listed below.
Population to One FTE Primary Care Physician
Is this Core Barrier Applicable?	[_] Yes [_] No
Data Response	___:1 (Ratio)
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data
Percent of Population Below 200 Percent of Poverty
Is this Core Barrier Applicable?	[_] Yes [_] No
Data Response	___ (%)
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data
Percent of Population Uninsured
Is this Core Barrier Applicable?	[_] Yes [_] No
Data Response	___ (%)
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data
Distance (miles) OR Travel Time (minutes) to Nearest Primary Care Provider Accepting New Medicaid and Uninsured Patients
Is this Core Barrier Applicable?	[_] Yes [_] No
Data Response	___ (Miles or Minutes)
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data

Section II: CORE HEALTH INDICATORS Note: Provide information for all six health indicator categories listed below. You are required to select one Core Health Indicator for each category and provide complete information for the selected indicator.
Diabetes
Core Health Indicator
National/Severe Benchmark	Pre-populated
Data Response
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data
Cardiovascular Disease
Core Health Indicator
National/Severe Benchmark	Pre-populated
Data Response
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data
Cancer
Core Health Indicator
National/Severe Benchmark	Pre-populated
Data Response
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data
Prenatal and Perinatal Health
Core Health Indicator
National/Severe Benchmark	Pre-populated
Data Response
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data
Child Health
Core Health Indicator
National/Severe Benchmark	Pre-populated
Data Response
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data
Behavioral Health
Core Health Indicator
National/Severe Benchmark	Pre-populated
Data Response
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data

Section III: OTHER HEALTH AND ACCESS INDICATORS Note: Provide information for 2 out of 13 of the Other Health and Access Indicators
Indicator #1
Other Health and Access Indicator
National Benchmark	Pre-populated
Data Response
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data
Indicator #2
Other Health and Access Indicator
National Benchmark	Pre-populated
Data Response
Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data

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 4.5 hours 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.