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Health Center Program Supplemental Information
ICR 202011-0915-002 · OMB 0915-0285 · Object 106610901.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Health Center Program Supplemental Information |
| Subject | SupplementalInformationForm |
| Author | HRSA |
| Last Modified By | Writer |
| File Modified | 2020-02-24 |
| File Created | 2026-09-14 |
| Conversion State | complete |
Extracted Text
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 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].