26 Form 12 - Clean

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Form 12: ORGANIZATION CONTACTS	FOR HRSA USE ONLY
	Grant Number	Application Tracking Number
Note: This form will pre-populate for competing continuation and competing supplement applicants.
Chief Executive Officer
Position Title
Prefix
Name
Suffix
Highest Degree
Email
Phone Number
Contact Person
Position Title
Prefix
Name
Suffix
Highest Degree
Email
Phone Number
Chief Medical Officer
Position Title
Prefix
Name
Suffix
Highest Degree
Email
Phone Number
Dental Director
Position Title
Prefix
Name
Suffix
Highest Degree
Email
Phone Number
Behavioral Health Director
Position Title
Prefix
Name
Suffix
Highest Degree
Email
Phone Number

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 30 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 Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].