Form 32 Health Center Program Supplemental Information - Clean.d

The Health Center Program Application Forms

Health Center Program Supplemental Information - Clean

Health Center Program: Supplemental Information

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

HEALTH CENTER PROGRAM:

SUPPLEMENTAL INFORMATION FORM

FOR HRSA USE ONLY

Grant Number

Application Tracking Number



Evidence-Based Strategies

Identify the evidence-based integration strategy(ies) that Expanded Services funding will help you implement and/or advance. Select all that apply. If you select “other evidence-based strategy,” you must complete the “Other Evidence-Based Strategy(ies)” section below.

Select All That Apply

Medication-Assisted Treatment

Collaborative Care Model

Patient-Centered Medical Home

Medicaid Health Homes

Four Quadrant Model

Assertive Community Treatment (ACT)

Integration of Mental Health, Substance Use, and Primary Care Services

Improving Mood-Promoting Access to Collaborative Treatment (IMPACT)

Screening, Brief Interventions, Referral to Treatment (SBIRT)

Other evidence-based strategy(ies)

Other Evidence-Based Strategy(ies)

If you selected “other evidence-based strategy(ies)” above, provide the strategy name and a publicly available URL demonstrating evidence that each other strategy identified is effective for its intended purpose. If your strategy includes multiple components, provide the name of the broader, overall strategy. If you plan to implement/advance more than three “other” strategies, include their information in an attachment.

Strategy name:

Reference:

Strategy name:

Reference:

Strategy name:

Reference:


Minor Alterations/Renovations

Are you proposing to use funding for minor alteration/renovation (A/R) that will support the expanded services?

If yes, HRSA will request additional information about your minor A/R plans separately after Expanded Services awards are announced. Expanded Services funds requested for minor A/R may not be obligated until required information is submitted and HRSA approves your A/R plans (6 to 9 months post award).

Select One Option

Yes, my health center’s Expanded Services proposal includes minor A/R costs, and I acknowledge that the A/R activities may not begin until HRSA approves our A/R plans

No, my health center’s Expanded Services proposal does not include minor A/R costs

Scope of Services

Review your current approved Form 5A: Services Provided. Will a Scope Adjustment or Change in Scope request be necessary to ensure that all planned changes to Expanded Services are on your Form 5A?


Access the technical assistance materials on the Scope of Project resource website for guidance in determining whether a Scope Adjustment or Change in Scope will be necessary (click on the “Services” header in the Resources section to access the Form 5A information).


If yes, you must separately submit a Scope Adjustment or Change in Scope request to HRSA. You may not modify your approved Form 5A through this application.

Select One Option

Yes, I reviewed my Form 5A and determined that my health center’s proposed activities will require a Scope Adjustment or Change in Scope request to modify Form 5A

No, I reviewed my Form 5A and determined that my health center’s proposed activities will not require a Scope Adjustment or Change in Scope request to modify Form 5A

If yes, describe the proposed changes and a timeline for requesting necessary modifications to your Form 5A below (Up to 1,000 characters counting spaces)


Staffing Impact


You must propose to increase at least 0.5 personnel FTE within 8 months of award. These personnel increases must be reported on progress reports and reflected in your 2020 annual Uniform Data System (UDS) report. Refer to the 2018 Uniform Data System Manual for staffing position definitions.

Staffing Positions by Major Service Category


New

Direct Hire Staff

FTEs Proposed

New Contractor

FTEs Proposed

Psychiatrists



Licensed Clinical Psychologists



Licensed Clinical Social Workers



Other Licensed Mental Health Providers

(e.g., psychiatric social workers, psychiatric nurse practitioners, family therapists)

Please Specify: [open text box]



Other Mental Health Staff

(e.g., “certified” individuals who provide counseling, treatment, or support to mental health providers)


Please Specify: [open text box]



Substance Use Disorder Providers



Family Physicians



General Practitioners



Internist



Obstetrician/Gynecologist



Pediatricians



Other Specialty Physicians and Sub-Specialists

(e.g., Emergency Medicine, Addiction Medicine, Pain Medicine, Infectious Disease)

Please Specify: [open text box]



Nurse Practitioners



Physician Assistants



Certified Nurse Midwives



Nurses



Other Medical Personnel (e.g., Medical

Assistants, Nurse Aides)



Laboratory Personnel



Pharmacy Personnel



Case Managers



Patient/Community Education Specialists



Outreach Workers



Transportation Staff



Eligibility Assistance Workers



Interpretation Staff



Community Health Workers



Other Enabling Services Staff

(e.g., staff who support outreach, care coordination, transportation)

Please Specify: [open text box]



Other Professional Health Services Staff

(e.g., physical therapists, occupational therapists, acupuncturists)

Please Specify: [open text box]



Subtotal

[Total calculated by EHB]

[Total calculated by EHB]

Total FTEs

[year 1 total calculated by 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 TitleHealth Center Program Supplemental Information
SubjectSupplementalInformationForm
AuthorHRSA
File Modified0000-00-00
File Created2021-01-14

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