19 Form 4 - Clean

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

Note: Data on race and/or ethnicity collected on this form will not be used as an awarding factor.

Race and Ethnicity	Service Area Population	Service Area Population Percent	Target Population	Target Population Percent
Asian		will auto-calculate in EHB		will auto-calculate in EHB
Native Hawaiian		will auto-calculate in EHB		will auto-calculate in EHB
Other Pacific Islanders		will auto-calculate in EHB		will auto-calculate in EHB
Black/African American		will auto-calculate in EHB		will auto-calculate in EHB
American Indian/Alaska Native		will auto-calculate in EHB		will auto-calculate in EHB
White		will auto-calculate in EHB		will auto-calculate in EHB
More than One Race		will auto-calculate in EHB		will auto-calculate in EHB
Unreported/Declined to Report (if applicable)		will auto-calculate in EHB		will auto-calculate in EHB
Total:	will auto-calculate in EHB	100%	will auto-calculate in EHB	100%

Hispanic or Latino Ethnicity	Service Area Population	Service Area Population Percent	Target Population	Target Population Percent
Hispanic or Latino		will auto-calculate in EHB		will auto-calculate in EHB
Non-Hispanic or Latino		will auto-calculate in EHB		will auto-calculate in EHB
Unreported/Declined to Report (if applicable)		will auto-calculate in EHB		will auto-calculate in EHB
Total:	will auto-calculate in EHB	100%	will auto-calculate in EHB	100%

Income as a Percent of Poverty Level	Service Area Population	Service Area Population Percent	Target Population	Target Population Percent
Below 100%		will auto-calculate in EHB		will auto-calculate in EHB
100-199%		will auto-calculate in EHB		will auto-calculate in EHB
200% and Above		will auto-calculate in EHB		will auto-calculate in EHB
Unreported/Declined to Report (if applicable)
Total:	will auto-calculate in EHB	100%	will auto-calculate in EHB	100%

Principal Third Party Payment Source	Service Area Population	Service Area Population Percent	Target Population	Target Population Percent
Medicaid		will auto-calculate in EHB		will auto-calculate in EHB
Medicare		will auto-calculate in EHB		will auto-calculate in EHB
Other Public Insurance		will auto-calculate in EHB		will auto-calculate in EHB
Private Insurance		will auto-calculate in EHB		will auto-calculate in EHB
None/Uninsured		will auto-calculate in EHB		will auto-calculate in EHB
Total:	will auto-calculate in EHB	100%	will auto-calculate in EHB	100%

Special Populations and Select Population Characteristics	Service Area Population	Service Area Population Percent	Target Population	Target Population Percent
Migratory/Seasonal Agricultural Workers and Families		will auto-calculate in EHB		will auto-calculate in EHB
People Experiencing Homelessness		will auto-calculate in EHB		will auto-calculate in EHB
Residents of Public Housing		will auto-calculate in EHB		will auto-calculate in EHB
School Age Children		will auto-calculate in EHB		will auto-calculate in EHB
Veterans		will auto-calculate in EHB		will auto-calculate in EHB
Lesbian, Gay, Bisexual, and Transgender		will auto-calculate in EHB		will auto-calculate in EHB
HIV/AIDS-Infected Persons		will auto-calculate in EHB		will auto-calculate in EHB
Individuals Best Served in a Language Other Than English		will auto-calculate in EHB		will auto-calculate in EHB
Other Please Specify (maximum 200 Characters): ______________		will auto-calculate in EHB		will auto-calculate in 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].