Form 1 Activity Registration

OMB No. 0906-0104
Expiration Date: 11/30/2026

Contact Information

HRSA IEA Activity Registration

First Name:
Last Name:
E-mail:
Telephone Number:
Job Title:
Organization:
City:
State:

1. Which category best describes your principal employment setting? (Select one)
Institutions of higher education:
College - Community
College or University
Non-profit entities:
Behavioral Health (Addiction or Mental Health) Services Organization - Nonprofit
Community or State Coalition
Community-Based Organization
Health Center
Health or Human Services Provider Organization – Nonprofit
Hospital - Nonprofit
Professional Association
Rural Health Clinic - Nonprofit
Private for-profit entities:
Behavioral Health (Addiction or Mental Health) Services Organization – For profit
Health or Human Services Provider Organization – For profit
Hospital – For profit
Rural Health Clinic – For profit
Small Business
Public entities:
Government – City, County or Local
Government – Federal
Government – State or U.S. Territory
Health Department – Local
Health Department - State
School or School District
Tribes and Tribal organizations:
Native American tribal governments
Native American tribal organizations
None of the above - Other
2. Has your current employer ever responded to a HRSA Notice of Funding Opportunity (i.e., applied
for a HRSA award)?
Yes
No
I do not know

OMB No. 0906-0104
Expiration Date: 11/30/2026

3. Does your organization currently receive a HRSA grant or cooperative agreement?
Yes
No
I do not know
4. Has your organization ever received a HRSA grant or cooperative agreement?
Yes
No
I do not know
5. Which category best describes your role?
Administrator
Board Member
Case Manager
Certified Nursing Assistant
Chiropractor
Clinical Nurse Specialist
Community Health Worker
Counselor
Dental Assistant
Dental Hygienist
Dentist
Executive or Senior Leader
Elected Official
Faculty
Government Health Official - State
Government Health Official – City, County, or Local
Health Educator
Health Services Psychologist
Home Visitor
Manager
Marriage and Family Therapist

Medical Assistant
Nurse Anesthetists
Nurse Midwife
Nurse Practitioner
Occupational Therapist
Peer Recovery Specialist
Practical Nurse
Professional Counselor
Psychologist
Psychiatric Nurse Specialist
Physical Therapist
Physician
Physician Assistant
Registered Nurse
Researcher
Social Worker
Student
Substance Use Disorder Counselor
Teacher
Tribal Leader
Other

OMB No. 0906-0104
Expiration Date: 11/30/2026

OPTIONAL QUESTIONS:
6. What is your preferred language?
English
Spanish
Other (please specify):
7. If you are a member of a Federally Recognized Tribe, to which Tribe do you belong?
Tribe:
8. Is your organization registered to apply for federal funding (i.e., have an active SAM.gov or
Grants.gov account)
Yes – with both Sam.gov and Grants.gov
Yes – with Sam.gov only
Yes – with Grants.gov only
No
I do not know
9. Would you like to receive e-mails about upcoming HRSA funding opportunities, events, and other
information?
Yes
No
10. What are your primary areas of interest? Check all that apply.
Behavioral Health (Mental Health or Substance Use)
Health Workforce
HIV/AIDS
Maternal and Child Health
Primary Care
Rural Health
Telehealth
Other:
Public Burden Statement: The purpose of this collection is to assist with preparing for, and evaluating the reach
and effectiveness of, select meetings and workshops conducted by HRSA’s Office of Intergovernmental and
External Affairs. An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number. The OMB control number for this
information collection is 0906-0104 and it is valid until 11/30/2027. This information collection is voluntary.
Data will be private to the extent permitted by the law. Public reporting burden for this collection of
information is estimated to average 3.33 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14NWH04,
Rockville, Maryland, 20857 or [email protected]. Please see https://www.hrsa.gov/about/508-resources
for the HRSA digital accessibility statement.