22E Form 5C - edits

The Health Center Program Application Forms

Form 5C - edits

Form 5C: Other Activities/Locations

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 5C: OTHER ACTIVITIES/LOCATIONS

FOR HRSA USE ONLY

Grant Number

Application Tracking Number



Activity/Location Information




Type of Activity (select one)

[_] Immunizations

[_] Hospital Admitting [_] Medical Rounds [_] Home Visits

[_] Health Fairs

[_] Non-Clinical Outreach [_] Portable Clinical Care [_] Health Education

[_] Other – Please Specify:

Frequency of Activity (max 600 characters)


Description of Activity (max 600 characters)


Type of Location(s) where Activity is Conducted



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 5C
AuthorHRSA
File Modified0000-00-00
File Created2021-01-14

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