Form 12 Organization Contacts

OMB No.: 0915-0285. Expiration Date: 9/30/2016

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 12: ORGANIZATION CONTACTS	FOR HRSA USE ONLY
	Application Tracking Number	Grant Number
Note: This form will pre-populate for competing continuation and competing supplement applicants.
Chief Executive Officer
Position Title
Prefix
Name
Suffix
Highest Degree
Email Phone
Phone NumberEmail
Contact Person
Position Title
Prefix
Name
Suffix
Highest Degree
Email Phone
Phone NumberEmail
Clinical Director
Position Title
Prefix
Name
Suffix
Highest Degree
Email Phone
Phone NumberEmail
Dental Director
Position Title
Prefix
Name
Suffix
Highest Degree
Email Phone
Phone NumberEmail

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 10.5 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-390-33, Rockville, Maryland, 20857.