24 Other requirement for sites (track changes)

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration OTHER REQUIREMENTS FOR SITES	FOR HRSA USE ONLY
	Application Tracking Number				Grant Number
	Project Number				Project Type
	Project Title
Site Information
Name of Service Site
Site Address
1. Site Control and Federal Interest
1a. Identify current status of property (If ‘Leased’, please provide Landlord Letter of Consentanswer Question 1b)
[_]Owned by the applicant [_] Leased/Occupancy Agreement
1b. If Leased, please check the following:
[_] The applicant certifies the following: The existing lease will provide the health center reasonable control of the project site; The existing lease is consistent with the proposed scope of project; We understand and accept the terms and conditions regarding Federal Interest in the property.
2. Cultural Resource Assessment and Historic Preservation Considerations (For Alteration/Renovation (A&R) projects ONLY)
2a. Was the facility constructed prior to 1975?				[_] Yes [_] No
2ba. Is the project facility 50 years or older?				[_] Yes [_] No
2cb. Does any element of the overall proposed work at the project site include: Aany renovation/modifications to the exterior of the facility (including thefor example: roof, HVAC, windows, siding, installation of new signage, exterior painting, generators, etc.), or Gground disturbance activityies ( for example: including expansion of building footprint, parking lot, sidewalks,installation of permanent access ramps, utilitites, etc.y work, installation of curb cuts, fencing, and parking)?				[_] Yes [_] No
2dc. Does the project involve renovation to a facility or site that is, or near a facility that is, historically, culturally, or architecturally, historically, or culturally significant?				[_] Yes [_] No
2ed. Is the site located on or nearcurrent or historic Native American, Alaskan Native, Native Hawaiian, or equivalent, culturally significant lands?				[_] Yes [_] No
Attachments
Landlord Letter of Consent (Maximum 1 attachment)
If property status is ‘Leased’ please applicant must provide Landlord Letter of Consent.
Property Information (Maximum 1 attachment)
If property status is ‘Leased’ or ‘Owned’ please provide Property Information.

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 .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-39, Rockville, Maryland, 20857