23E Form 6A - edits

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX
DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 6A: CURRENT BOARD MEMBER CHARACTERISTICS	FOR HRSA USE ONLY
	Grant Number	Application Tracking Number
Note: The list of Board Members will pre-populate for competing continuation and competing supplement applicants.

Name

Current Board Office Position Held

Area of Expertise

>10% of Income from Health Industry

Health Center Patient

Live or Work in Service Area

Special Population Representative

(If yes, specify Special Population)

PATIENT BOARD MEMBER CLASSIFICATION

Gender

Number of Patient Board Members

Male

Female

Unreported/Declined to Report

Ethnicity

Number of Patient Board Members

Hispanic or Latino

Non-Hispanic or Latino

Unreported/Declined to Report

Race

Number of Patient Board Members

Native Hawaiian

Other Pacific Islanders

Asian

Black/African American

American Indian/Alaska Native

White

More Than One Race

Unreported/Declined to Report

Note: This section is ONLY required if you selected Public (non-Tribal or Urban Indian) as the Business Entity on Form 1A of this application. In all other cases, select N/A.

If the applicant is a public organization/center, do the board members listed above represent a co-applicant board?

Yes

No

N/A

If yes, ensure that the co-applicant agreement is included as Attachment 6 in the Appendices form of this application.

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. . [email protected] HYPERLINK "https://sharepoint.hrsa.gov/sites/bphc/oppd/ED1/OMB%20Forms%20Approval%202020/[email protected]" 42 U.S.C. 254b HYPERLINK "http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim"