Form 26 Form 12 - Clean

The Health Center Program Application Forms

Form 12 - Clean

Form 12: Organization Contacts

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 12: ORGANIZATION CONTACTS

FOR HRSA USE ONLY

Grant Number

Application Tracking Number



Note: This form will pre-populate for competing continuation and competing supplement applicants.

Chief Executive Officer

Position Title


Prefix


Name


Suffix


Highest Degree


Email


Phone Number


Contact Person

Position Title


Prefix


Name


Suffix


Highest Degree


Email


Phone Number


Chief Medical Officer

Position Title


Prefix


Name


Suffix


Highest Degree


Email


Phone Number


Dental Director

Position Title


Prefix


Name


Suffix


Highest Degree


Email


Phone Number


Behavioral Health Director

Position Title


Prefix


Name


Suffix


Highest Degree


Email


Phone Number


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 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 14N136B, Rockville, Maryland, 20857 or [email protected].




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleForm 12 - Organization Contacts
AuthorSurbhi Taori
File Modified0000-00-00
File Created2021-01-14

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