Form 25 Form 8 - Clean

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Form 8: HEALTH CENTER AGREEMENTS	FOR HRSA USE ONLY
	Grant Number	Application Tracking Number
Note: If a Health Center Program award recipient wishes to enter into an agreement/arrangement post-award that will either (1) result in another organization carrying out a substantial portion of the approved scope of project or (2) impact the governing board’s composition, authorities, functions, or responsibilities, a Prior Approval request must be submitted in EHB and approved by HRSA before the agreement/arrangement can be formalized and implemented.
PART I Health Center Agreements
1. Does your organization have a parent, affiliate, or subsidiary organization?			[_]Yes [_] No
Do you currently have, or plan to utilize a) Contract(s) with another organization to perform substantive programmatic work within the proposed scope of project? For the purposes of the Health Center Program, contracting for substantive programmatic work applies to contracting with a single entity for the majority of health care providers. Or b) Subawards to carry out a portion of the proposed scope of project. The purpose of a subaward is to carry out a portion of the Federal award and creates a Federal assistance relationship with the subrecipient. NOTE: Subawards or contracts made to related organizations such as a parent, affiliate, or subsidiary must be addressed in this form. The acquisition of supplies, material, equipment, or general support services (e.g., janitorial services, contracts with individual providers) is not considered programmatic work. If Yes, indicate the number of each agreement by type in 2a and/or 2b below and complete Part II. If No, Part II is Not Applicable.			[_]Yes [_] No
2a. Number of contracts with another organization to perform substantive programmatic work within the proposed scope of project.			(number)
2b. Number of subawards made to subrecipients to carry out a portion of the proposed scope of project.			(number)
2c. Total number of contracts and/or subawards for a substantial portion of the proposed scope of project.			(number)
Part II: Attachments All contracts or subawards, including those which involve a parent, affiliate, or subsidiary organization referenced in Part I must be uploaded in full. Uploaded documents will NOT count against the page limit.
Affiliate/Contract/Subaward Organization Name (maximum 50 characters)
Type of Agreement	[_] Affiliation Agreement [_] Subaward [_] Contract

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].