23 Equipment List Final

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

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

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 14N-39, Rockville, Maryland, 20857.

INSTRUCTIONS

Applicants requesting funding for equipment purchases must submit a complete list of the requested equipment in EHB. For each item on the equipment list, the following fields must be completed:

• Type – Select clinical or non-clinical.

• Item Description – Provide a description of each item.

• Unit Price – Enter the price of each item.

• Quantity – Enter of the number of each item to be purchased.

• Total Price – EHB will calculate the total price by multiplying the unit price by the quantity entered.

Any equipment purchased with grant funds must be pertinent to health center operations. Further, equipment purchased with grant funds must be procured through a competitive process and maintained, tracked, and disposed of in accordance with 45 CFR 75.