Form 23 Equipment List (track changes)

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration EQUIPMENT LIST		FOR HRSA USE ONLY
		Application Tracking Number				Grant Number
		Project Number				Project Type
		Project Title
List of Equipment
Type	Description		Unit Price				Quantity		Total Price
[_] Clinical [_] Non Clinical [_] Mobile Van
[_] Clinical [_] Non Clinical [_] Mobile Van
[_] Clinical [_] Non Clinical [_] Mobile Van
[_] Clinical [_] Non Clinical [_] Mobile Van
[_] Clinical [_] Non Clinical [_] Mobile Van
Total

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

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