Form 19 Form 4 - Clean

The Health Center Program Application Forms

Form 4 - Clean

Form 4: Community Characteristics

OMB: 0915-0285

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

Form 4: Community Characteristics

Note: Data on race and/or ethnicity collected on this form will not be used as an awarding factor.

Race and Ethnicity

Service Area Population

Service Area Population Percent

Target Population

Target Population Percent

Asian


will auto-calculate in EHB


will auto-calculate in EHB

Native Hawaiian


will auto-calculate in EHB


will auto-calculate in EHB

Other Pacific Islanders


will auto-calculate in EHB


will auto-calculate in EHB

Black/African American


will auto-calculate in EHB


will auto-calculate in EHB

American Indian/Alaska Native


will auto-calculate in EHB


will auto-calculate in EHB

White


will auto-calculate in EHB


will auto-calculate in EHB

More than One Race


will auto-calculate in EHB


will auto-calculate in EHB

Unreported/Declined to Report

(if applicable)


will auto-calculate in EHB


will auto-calculate in EHB

Total:

will auto-calculate in EHB

100%

will auto-calculate in EHB

100%


Hispanic or Latino Ethnicity

Service Area Population

Service Area Population Percent

Target Population

Target Population Percent

Hispanic or Latino


will auto-calculate in EHB


will auto-calculate in EHB

Non-Hispanic or Latino


will auto-calculate in EHB


will auto-calculate in EHB

Unreported/Declined to Report

(if applicable)


will auto-calculate in EHB


will auto-calculate in EHB

Total:

will auto-calculate in EHB

100%

will auto-calculate in EHB

100%


Income as a Percent of Poverty Level

Service Area Population

Service Area Population Percent

Target Population

Target Population Percent

Below 100%


will auto-calculate in EHB


will auto-calculate in EHB

100-199%


will auto-calculate in EHB


will auto-calculate in EHB

200% and Above


will auto-calculate in EHB


will auto-calculate in EHB

Unreported/Declined to Report (if applicable)





Total:

will auto-calculate in EHB

100%

will auto-calculate in EHB

100%


Principal Third Party Payment Source

Service Area Population

Service Area Population Percent

Target Population

Target Population Percent

Medicaid


will auto-calculate in EHB


will auto-calculate in EHB

Medicare


will auto-calculate in EHB


will auto-calculate in EHB

Other Public Insurance


will auto-calculate in EHB


will auto-calculate in EHB

Private Insurance


will auto-calculate in EHB


will auto-calculate in EHB

None/Uninsured


will auto-calculate in EHB


will auto-calculate in EHB

Total:

will auto-calculate in EHB

100%

will auto-calculate in EHB

100%


Special Populations and

Select Population Characteristics

Service Area Population

Service Area Population Percent

Target Population

Target Population Percent

Migratory/Seasonal Agricultural Workers and Families


will auto-calculate in EHB


will auto-calculate in EHB

People Experiencing Homelessness


will auto-calculate in EHB


will auto-calculate in EHB

Residents of Public Housing


will auto-calculate in EHB


will auto-calculate in EHB

School Age Children


will auto-calculate in EHB


will auto-calculate in EHB

Veterans


will auto-calculate in EHB


will auto-calculate in EHB

Lesbian, Gay, Bisexual, and Transgender


will auto-calculate in EHB


will auto-calculate in EHB

HIV/AIDS-Infected Persons


will auto-calculate in EHB


will auto-calculate in EHB

Individuals Best Served in a Language Other Than English


will auto-calculate in EHB


will auto-calculate in EHB

Other

Please Specify (maximum 200 Characters): ______________


will auto-calculate in EHB


will auto-calculate in EHB


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 TitleForm 4
AuthorBeth Hartmayer
File Modified0000-00-00
File Created2021-01-14

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