38 Patient Target and Calculation

The Health Center Program Application Forms

Patient Target and Calculation

OMB: 0915-0285

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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


Shape1

Request Update


Shape2

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




Shape3

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].


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorHartmayer, Beth (HRSA)
File Modified0000-00-00
File Created2023-08-25

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