Form 11 Federal Object Class Category Form- clean

The Health Center Program Application Forms

Federal Object Class Category Form- clean

Federal Object Class Categories

OMB: 0915-0285

Document [docx]
Download: docx | pdf



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


DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

Federal Object Class Categories Form

FOR HRSA USE ONLY

Grant Number

Application Tracking Number



Object Class Category

Year 1

Year 2

Total

[Calculated by EHB]


Federal

Non-Federal

Federal

Non-Federal

Year 1

Year 2

a. Personnel







b. Fringe Benefits







c. Travel







d. Equipment







e. Supplies







f. Contractual







g. Construction







h. Other







i. Total Direct Charges (sum of a‑g6otal Direct Charges (sum of 6)







j. Indirect Charges







k. Total Budget Specified in Section A - Budget Summary (sum of h - i)

[Calculated by EHB]

Total Y1 Federal


Total Y2 Federal





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 15 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
AuthorMcDevitt, Shannon (HRSA)
File Modified0000-00-00
File Created2021-01-14

© 2024 OMB.report | Privacy Policy