Form 9 Equipment List

The Health Center Program Application Forms

Equipment List - clean

Equipment List

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

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: 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. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). 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 14N136B, Rockville, Maryland, 20857 or [email protected].






File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleEquipment List
SubjectEquipment List
AuthorHRSA
File Modified0000-00-00
File Created2021-01-14

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