Form 13 Applicant Qualification Criteria Form

OMB No.: 0915-0285. Expiration Date: 3/31/2023

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

APPLICANT QUALIFICATION CRITERIA FORM

Applicant Information

• Select the response for each question that most appropriately answers the question.

• This form is being used to validate that your SBHC will comply with all requirements, as indicated in section 399Z–1 of the Public Health Service Act (42 U.S.C. 280h-5).

• Please note that:

  • Only school-based health centers that currently meet or will meet the definition of a school-based health center under section 2110(c)(9)(A) of the Social Security Act after verifying that they are operating in compliance with all program requirements and assurances within 120 days of award AND are administered by a sponsoring facility (as defined in section 2110(c)(9)(B) of the Social Security Act) are eligible to receive funding under this notice. Selecting “Other” will result in an ineligible application.

  • Current award recipients under section 330(e), (g), (h), (i), and/or (l) of the Public Health Service Act (42 U.S.C. § 254b), including but not limited to H80, U30, U58, and H2Q, are not eligible SBHC applicants. Selecting “Yes” to Question 2 will result in an ineligible application.

  • Only the 6 sponsoring facility types listed under Question 6 are allowable under this funding. Selecting “Other” will result in an ineligible application.

  • Selecting “No” for any of Questions 3-5 and 7-19 will result in an ineligible application.

1. Applicant is:

[_] A currently operational school-based health center that meets the definition of a school-based health center under section 2110(c)(9)(A) of the Social Security Act AND is administered by a sponsoring facility (as defined in section 2110(c)(9)(B) of the Social Security Act).

[_] A proposed school-based health center that will meet the definition of a school-based health center under section 2110(c)(9)(A) of the Social Security Act within 120 days of award AND is administered by a sponsoring facility (as defined in section 2110(c)(9)(B) of the Social Security Act).

[_] Other, please describe. [TEXT BOX]

2. Is the applicant SBHC a current recipient of funding under section 330 of the Public Health Service Act (42 U.S.C. § 254b)? This includes, but is not limited to Health Center Program H80 award recipients, and subrecipients and contractors that operate a H80 site, as well as other recipients of Health Center Program funding (e.g., U30 (NTTAP), U58 (PCA), and H2Q (HCCN)).

[_] Yes [_] No

3. Is the applicant SBHC located in or near (defined as immediately adjacent to) a school facility of a school district or board, or a school facility of an Indian tribe or tribal organization?

[_] Yes [_] No

4. Is the applicant SBHC organized through school, community, and health provider relationships?

[_] Yes [_] No

5. Is the applicant SBHC administered by a sponsoring facility as defined in section 2110(c)(9)(B) of the Social Security Act?

[_] Yes [_] No

6. The sponsoring facility is a:

[_] Hospital

[_] Public Health Department

[_] Community Health Center (A Health Center Program H80 award recipient may serve as the sponsoring facility, but may not receive SBHC grant funds, either directly or indirectly through a contract.)

[_] Non-Profit Health Care Agency

[_] Local Educational Agency (as defined in 20 USC 7801(30(A), including a public board of education or other public authority legally constituted within a State for either administrative control or direction of, or to perform a service function for, public elementary schools or secondary schools in a city, county, township, school district, or other political subdivision of a State, or of or for a combination of school districts or counties that is recognized in a State as an administrative agency for its public elementary schools or secondary schools)

[_] A program administered by the Indian Health Service or the Bureau of Indian Affairs or operated by Indian Tribe or a Tribal Organization

[_] Other, please describe. [TEXT BOX]

7. Is the applicant SBHC providing, or proposing to provide, through health professionals, comprehensive primary health services (including physical and mental health services as defined in 42 USC 280h-5(a)(1)) to children and adolescents during school hours in accordance with State and local law, including laws relating to licensure and certification?

[_] Yes [_] No

8. Is or will the applicant SBHC be in compliance with related requirements the State may establish for the operations of such a clinic, including established standards, community practice, reporting laws, and other State laws that are not inconsistent with Federal law?

[_] Yes [_] No

9. I certify that SBHC services will be provided to children and adolescents for whom parental or guardian consent has been obtained in cooperation with Federal, State, and local laws governing health care service provision to children and adolescents.

[_] Yes [_] No

10. I certify that the SBHC has made and will continue to make every reasonable effort to establish and maintain collaborative relationships with other health care providers in the catchment area of the SBHC.

[_] Yes [_] No

11. I certify that the SBHC will provide on-site access during the academic day when school is in session and 24- hour coverage through an on-call system and through its backup health providers to ensure access to services on a year-round basis when the school or the SBHC is closed.

[_] Yes [_] No

12. I certify that the SBHC will be integrated into the school environment and will coordinate health services with school personnel, such as administrators, teachers, nurses, counselors, and support personnel, as well as with other community providers co-located at the school.

[_] Yes [_] No

13. I certify that the SBHC sponsoring facility assumes all responsibility for the SBHC administration, operations and oversight.

[_] Yes [_] No

14. I certify that the SBHC will comply with Federal, State, and local laws concerning patient privacy and student records, including regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 and 20 USC 1232g.

[_] Yes [_] No

15. I certify that the SBHC does not and will not perform abortion services.

[_] Yes [_] No

16. I certify that the SBHC will only provide age appropriate services.

[_] Yes [_] No

17. I certify that the SBHC will not provide services to an individual without the consent of the parent or guardian of such individual if such individual is considered a minor under applicable State law.

[_] Yes [_] No

18. I certify that the SBHC will notify HRSA if any provider of services is determined by a State to be in violation of a State law with respect to activities carried out at the SBHC (provision of comprehensive primary health services during school hours to children and adolescents by health professionals in accordance with established standards, community practice, reporting laws, and other State laws, including parental consent and notification laws that are not inconsistent with Federal law) and understand that the SBHC shall not be eligible to receive additional HRSA SBHC funding if there is a violation of state law.

[_] Yes [_] No

19. I certify that grant funds provided under the SBHC award shall be used to supplement, not supplant, other Federal or State funds.

[_] Yes [_] No

Public Burden Statement: The OMB control number for this information collection is 0915-0285 and it is valid until 3/31/2023. 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].