Form 38 Patient Target and Calculation

Patient Target Details

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

Patient Target Details
Grant Number: H80CSXXXXX	Grantee Name:		Patient Target:
Resources
Reviewer Change Request Comment		Action History
Patient Target Calculation
Base Value: FY 2017 SAC Continuation Award
FY 2018 SUD-MH Supplemental Award
FY 2017 AIMS Supplemental Award
Patient Target
Request Update
Confirm Patient Target

Patient Target Projections Revisions

Patient Target Projections Revision
Note: Provide a justification for the value entered in the Proposed Projection field, including where evidence for the requested update can be found in the funded application. Email [email protected] for guidance before submitting this request.
Source	Reported Patient Projection	Proposed Projection	Justification
Base Value: FY 2017 SAC Continuation Award
FY 2018 SUD-MH Supplemental Award
FY 2017 AIMS Supplemental Award
Patient Target
Submit to HRSA

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].