Form 12 Proposal Cover Page

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

PROPOSAL COVER PAGE

FOR HRSA USE ONLY

Application Tracking #

Grant Number

1. Applicant Eligibility

Is the applicant organization currently an existing health center under the Section 330 Program?

^{(If ‘Yes’ please provide the H80 grant number below.)}

[_] Yes [_] No

H80 Grant Number (Example: H80CS00001)

2. Need

Describe the existing state of the facility. Describe how the facility deficiencies have impacted the ability to adequately staff and operate the health center. Indicate whether or not the proposed project has started construction activities and/or issued a construction contract. Provide a justification for the equipment requested and its appropriateness with the facility improvement(s).

(Maximum 8000 characters)

3. Response

Indicate how the health center will support operating costs, including increases in utilities, daily maintenance and repair, and capital reinvestment for the identified project(s). Explain how the health center will maintain the facility improvements resulting from the project(s) within its existing operational budget—applicants must demonstrate that no ongoing section 330 support is required. If appropriate, describe how the organization will pay or retire the capital debt related to the proposal. Provide evidence of support from the community, stakeholders, and patient population.

(Maximum 4000 characters)

4. Service Impacts

Describe how the proposed project(s) will enhance the quality of care and patient outcomes, and improve access to care within the community. Describe how the proposed project(s) will promote the sustainability of the services provided by the health center once the project has been completed.

(Maximum 4000 characters)

5. Resources/Capabilities

Describe how the health center has the appropriate resources and capabilities to successfully implement and complete the proposed project(s) (e.g., prior experience, project management capabilities). Identify the health center’s acquisition strategy, policies, and procedures, and how the project(s) will comply with Federal procurement requirements. Explain how the applicant organization will ensure the project(s) will be completed on time (within the 2-year project period) and within budget (e.g., role of the board, management team, project team).

(Maximum 4000 characters)

6. Funding Priority

Attached Document (Maximum 1 attachment)
Purpose	Document Name	Size	Uploaded By	Description

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].