23E Form 6A - edits

The Health Center Program Application Forms

Form 6A - edits

Form 6A: Current Board Member Characteristics

OMB: 0915-0285

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FORM 6A: CURRENT BOARD MEMBER CHARACTERISTICS

FOR HRSA USE ONLY

Grant Number

Application Tracking Number

Note: The list of Board Members will pre-populate for competing continuation and competing supplement applicants.


Name

Current Board Office Position Held

Area of Expertise

>10% of Income from Health Industry

Health Center Patient

Live or Work in Service Area

Special Population Representative

(If yes, specify Special Population)
































































PATIENT BOARD MEMBER CLASSIFICATION

Gender

Number of Patient Board Members

Male


Female


Unreported/Declined to Report


Ethnicity

Number of Patient Board Members

Hispanic or Latino


Non-Hispanic or Latino


Unreported/Declined to Report


Race

Number of Patient Board Members

Native Hawaiian


Other Pacific Islanders


Asian


Black/African American


American Indian/Alaska Native


White


More Than One Race


Unreported/Declined to Report


Note: This section is ONLY required if you selected Public (non-Tribal or Urban Indian) as the Business Entity on Form 1A of this application. In all other cases, select N/A.

If the applicant is a public organization/center, do the board members listed above represent a co-applicant board?

Shape1 Yes

Shape2 No

Shape3 N/A


If yes, ensure that the co-applicant agreement is included as Attachment 6 in the Appendices form of this application.


Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. . [email protected] HYPERLINK "https://sharepoint.hrsa.gov/sites/bphc/oppd/ED1/OMB%20Forms%20Approval%202020/[email protected]" 42 U.S.C. 254b HYPERLINK "http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim"


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleForm 6A
AuthorRahul Sahi
File Modified0000-00-00
File Created2021-01-14

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