Form 24 Form 6B - Clean

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 6B: REQUEST FOR WAIVER OF BOARD MEMBER REQUIREMENTS	FOR HRSA USE ONLY
	Grant Number		Application Tracking Number
Note: This form is applicable if you are proposing to serve only special populations (i.e., HCH,MHC, and/or PHPC)
Request for Waiver
Name of Organization		Will pre-populate in EHB
1. New Waiver Request
Are you requesting a new waiver of the 51% patient majority governance requirement?		[_] Yes [_] No
2. For Applicants with Previous Waiver
2a. Do you currently have a waiver of the 51% patient majority governance requirement?		[_] Yes [_] No
2b. Are you requesting the patient majority waiver to be continued? (This question is required if you answered yes to question 2a.)		[_] Yes [_] No (Governing board is in full compliance)
3. Demonstration of Good Cause for Waiver (Demonstrate good cause for the waiver request by addressing the following areas)
3a. Provide a description of the population to be served and the characteristics of the population/service area that would necessitate a waiver. This question is required if you answered 'Yes' to question 1 and/or question 2b.) (maximum 1,000 characters)
3b. Provide a description of the health center’s attempts to meet the requirement to date and explain why these attempts have not been successful. This question is required if you answered 'Yes' to question 1 and/or question 2b.) (maximum 1,000 characters)
4. Alternative Mechanism Plan for Addressing Patient Representation
Present a plan for complying with the intent of the statute via an alternative mechanism that ensures patient input and participation in the organization, as well as direction and ongoing governance of the health center. (This question is required if you answered 'Yes' to question 1 and/or question 2b.) (maximum 1,000 characters)

Public Burden Statement: The Uniform Data System (UDS) provides consistent information about health centers including patient demographics, services 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].