Form 22 Project Cover Page (track changes)

OMB No.: 0915-0285     Expiration Date: 10/31/2013XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration ALTERATION/RENOVATION (A/R) PROJECT COVER PAGE	FOR HRSA USE ONLY
	Application Tracking Number	Grant Number

NAME OF SITE:

Physical Address

Mailing Address

Are you requesting federal one-time funding for alteration/renovation for this site?

[_] Yes    [_] No

1. Site Information
Name of Service Site		Site Address
Improved Project Square Footage
2. Project Description
Provide a detailed description of the scope of work for the A/R project. Identify the major clinical and non-clinical spaces that will result from the project. Include the area (in square feet) or dimensions of the spaces to be altered, or renovated. The description should also list major improvements, such as permanently affixed equipment to be installed; modifications and repairs to the building exterior (including windows); heating, ventilation and air conditioning (HVAC) modifications (including the installation of climate control and duct work); electrical upgrades; plumbing work; and any work outside the building. Describe how the applicant will reduce the project's potential adverse impacts on the environment. Indicate whether or not the project will implement green/sustainable design practices/principles (e.g., using project materials, design/renovation strategies, equipment selection, etc.). (maximum 4,000 characters)
3. Project Management/Resources/Capabilities
Explain the administrative structure and oversight for the A/R project, including the role and responsibilities of the health center’s key management staff as well as oversight by the governing board. Identify the individual who will be the Project Manager and the individuals who comprise the Project Team responsible for managing the project. Describe how the Project Team has the expertise and experience necessary to successfully manage and complete the project within the 120 day timeline and achieve the goals and objectives established for this project. (maximum 4,000 characters)
4. Is the proposed alteration/renovation project (ONLY) part of a larger scale renovation, construction or expansion project?
Please provide a response below:
Yes [_] No [_]
Attachments:
Provide following documents related to this site: A/R Budget Justification (required) (Maximum 1 document) Environmental Information Documentation (EID) Checklist (required) (Maximum 1 document) Floor Plans/Schematic Drawings (required) (Maximum 2 documents) Other Project Documents (optional) (Maximum 1 document)

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 1014N-393, Rockville, Maryland, 20857