36 Other Requirements for Sites

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration OTHER REQUIREMENTS FOR SITES	FOR HRSA USE ONLY
	Grant Number	Application Tracking Number
Site Information
Name of Service Site
Site Address
1. Site Control and Federal Interest
1a. Identify current status of property site (If ‘Leased’, please answer Question 1b)
[_] Owned [_] Leased
1b. If Leased, please check the following:
[_] The applicant certifies the following: The existing lease will provide the health center reasonable control of the project site; The existing lease is consistent with the proposed scope of project; We understand and accept the terms and conditions regarding Federal Interest in the property.
2. Cultural Resource Assessment and Historic Preservation Considerations
2a. Was the project facility constructed prior to 1975?
[_] Yes [_] No
2b. Is the project facility 50 years or older?
[_] Yes [_] No
2c. Does any element of the overall work at the project site include: Any renovation/modifications to the exterior of the facility (for example: roof, HVAC, windows, siding, signage, exterior painting, generators, etc.) or Ground disturbance activity (for example: expansion of building footprint, parking lot, sidewalks, utilities, etc.)?
[_] Yes [_] No
2d. Does the project involve renovation to a facility that is, or near a facility that is, architecturally, historically, or culturally significant?
[_] Yes [_] No
2e. Is the site located on or near Native American, Alaskan Native, Native Hawaiian, or equivalent culturally significant lands?
[_] Yes [_] No
Attachments
Landlord Letter of Consent (Maximum 1 attachment) If property status is ‘Leased’, applicant must provide Landlord Letter of Consent.
Property Information (Maximum 1 attachment) If property status is ‘Leased’ or ‘Owned’ please provide Property Information.

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].