Form 36 Supplemental 2017

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration HEALTH CENTER PROGRAM: SUPPLEMENTAL INFORMATION FORM					FOR HRSA USE ONLY
					Grant Number				Application Tracking Number
1) New Provider Staff				Direct Hire Staff FTEs (a)			Contracted FTEs (b)				Total Onsite FTEs (c) (1a+1b)
											Auto-calculated
											Auto-calculated
Total Direct and Contractor FTEs:											Auto-calculated
2) Projected Patient Confirmation										Patients from Form 1A/ Confirmations
New patients resulting from Project as of December 31, 2018										Prepopulated from Form 1A
By checking the certification box, I confirm that the projected calendar year 2018 NEW patient number is accurate (includes only patients NEW to the health center that become health center patients as a result of the expanded services and will be served between January 1, 2018 and December 31, 2018). If not accurate, revisit Form 1A and correct the total projected patient number in the “Unduplicated Patients and Visits by Population Type” table. *This number will be added to your Patient Target.										☐
3) Summary of changes to Form 5A: Services proposed in the application Prepopulated from Form 5A
The table below indicates the services on Form 5A that were added or modified in this application. Services that are currently in-scope and that do not require modification as part of the proposal are not listed here. Note: Within 120 days of award, health centers will be required to verify that the Form 5A changes summarized below have been implemented. Health centers should NOT propose new services if they will not meet the 120-day implementation deadline. If the proposed updates listed below are not correct, visit Form 5A and make changes as needed.
REQUIRED SERVICES	Currently Approved Form 5A					Updated Form 5A
Service Type	Column I (Direct – Health Center Pays)	Column II (Formal Written Contract – Health Center Pays)	Column III (Formal Referral – Health Center DOES NOT pay)			Column I (Direct – Health Center Pays)		Column II (Formal Written Contract – Health Center Pays)				Column III (Formal Referral – Health Center DOES NOT pay)
Service	[_]	[_]	[_]			[_]		[_]				[_]
Service	[_]	[_]	[_]			[_]		[_]				[_]

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 30 minutes 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.