Form 35 Operational Plan - clean

The Health Center Program Application Forms

Operational Plan - clean

Operational Plan

OMB: 0915-0285

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


Operational Plan


The Operational Plan must be specific to the proposed NAP project, with appropriate and reasonable time-framed goals and action steps necessary to achieve the following within 120 days of the Notice of Award:

  1. All proposed sites (as noted on Form 5B: Service Sites) must have the necessary staff and providers in place to begin operating and delivering services, as described on Forms 5A: Services Provided and 5C: Other Activities/Locations. If required services are provided by contract or referral, specify action steps and timeframes for the development of these formal arrangements.

  2. Your health center must be compliant with all Health Center Program requirements detailed in the Compliance Manual.


You may choose focus areas and goals based on the list below, or develop your own, as appropriate. If you are currently operational and compliant with Health Center Program requirements, state your compliance status and highlight proposed changes in access to care, such as planned service expansion and outreach activities, new collaborations or partnerships, and any other changes that would occur as a result of the NAP funding. Use the Compliance Manual and Site Visit Protocol to assess your compliance with Health Center Program requirements.

Goal

On separate rows, identify the goals for each focus area. Goals should describe measureable results.

Key Action Steps

Identify the action steps that must occur to accomplish each goal.

Person/Area Responsible

Identify who will be responsible and accountable for carrying out each action step.

Time Frame

Identify the expected time frames for carrying out each action step.

Comments

As desired, provide supplementary information.

Focus Area: Operational Service Delivery

Goal A1

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal A2

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal A3

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal A4

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal A5

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal A6

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Focus Area: Functioning Key Management Staff/Systems/Arrangements

Goal B1

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal B2

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal B3

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal B4

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Focus Area: Implementation of Sliding Fee Discount Program

Goal C1

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal C2

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal C3

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Focus Area: Quality Improvement/Quality Assurance (QI/QA) Program

Goal D1

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal D2

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal D3

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Focus Area: Governing Board

Goal E1

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal E2

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal E3

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal E4

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Focus Area: Other

Goal F1

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal F2

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame


Goal F3

  1. Action Step

  1. Person Responsible

  1. Time Frame



  1. Action Step

  1. Person Responsible

  1. Time Frame



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 3 hours 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 TitleSample SAC/SAC-AA Operational Plan
SubjectNAP Implementation Plan
AuthorHRSA
File Modified0000-00-00
File Created2021-01-14
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