Checklist for Adding a Service Site to Scope

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Checklist for Adding a Service Site to Scope

Background
Your change in scope (CIS) request will not become part of your health center’s HRSA-approved Health Center Program scope of project until all the following steps have been completed: 
    1. HRSA sends your health center the Notice of Award (NoA) or Notice of Look-Alike Designation (NLD) approving the CIS request; 
    2. Next, your health center submits a scope verification task that confirms your health center has implemented the change. HRSA will allow up to 120 days for your health center to submit the scope verification task; and 
    3. Finally, HRSA sends your health center an NoA or NLD documenting that the change is included in your health center’s scope of project. 
For more information, refer to the Scope of Project Resources. 

    1. Has your health center recently submitted or is it in the process of submitting any other CIS requests related to this site or related to any attachments within this CIS request? 
For example, contracts or agreements within this CIS request are referenced within other CIS requests or your health center previously submitted a CIS request to add this site that HRSA disapproved.
    • Yes 
    • No 

        1.1 If YES: Provide the CIS tracking numbers and describe the connection to this CIS request. For example, the same contract, same school-based agreement, same subaward agreement, adding a new service at the proposed site, why you are submitting another CIS request for this site that HRSA previously disapproved.
 [textbox] 

    2. Is this CIS request a scope correction in preparation for or resulting from one or more site visits?
    • Yes 
    • No 

        2.1 IF YES: Identify the related site visits.
[textbox] 

        2.2 If YES: Explain. [textbox] 


Description and Rationale
    3. Why are you requesting to add this proposed site to your health center’s scope of project? 
Select all that apply:
    • Your health center is exceeding capacity at one or more current sites.
Explain: [textbox]
    • Your health center has an opportunity to expand access to services. 
Explain: [textbox]
    • An existing provider in the area is closing a site or no longer offering services to the patient population. Explain: [textbox]
    • This is a comparable site for a site that was awarded via a funding opportunity (for example, New Access Point, supplemental funding for site construction or renovation) but that is no longer available. 
Select any Health Center Program supplemental awards related to this site: 
[Multi-select]  
    • Other – Explain: [textbox]

    4. Will the addition of the proposed site change your health center’s governance structure?
    • Yes
    • No

        4.1 If YES: Explain how your health center’s governance structure will change, including any impacts on your health center’s governing board authorities (for example, another organization reserves authorities over your health center’s governing board). [textbox]

    5. Service Area ZIP Codes
5.1 All Current Service Area ZIP Codes
These are all the current service area ZIP Codes for all your health center’s in-scope sites, based on your health center’s Form 5B: Sites. [textbox or electronic system auto-population]
5.2 Proposed Site’s Service Area ZIP Codes
These are all service area ZIP Codes for the proposed site. [textbox or electronic system auto-population]
5.3 New Service Area ZIP Codes Due To Proposed Site
These are only the new service area ZIP Codes that are in the service area ZIP Codes for the proposed site (5.2) but are not part of your health center’s current service area (5.1). [textbox or electronic system auto-population]
5.4 For any new service area ZIP Codes that are not part of your health center’s current service area, explain why your health center is proposing to expand its service area. [textbox]
5.4.1 If any new service area ZIP Codes are not adjacent to your health center’s current service area, explain why your health center is proposing to serve non-adjacent ZIP Codes. [textbox]
5.4.2 If any new service area ZIP Codes include political subdivisions, including school districts, not previously served by your health center, explain how your health center will address barriers resulting from the new service area's physical characteristics, residential patterns, and available transportation. [textbox]

    6 The proposed site is located outside of your health center’s current service area: Is the proposed site significantly distant from the nearest border of your health center’s current service area (for example, greater than 15 miles in an urban area or greater than 30 miles in a rural area)?
    • Yes
    • No

        6.1 If YES: Specify the distance (in miles) of the proposed site to the nearest border of your health center’s current service area, and explain the rationale for locating the proposed site at that distance from your health center’s current service area: [textbox] 

    7. What is the distance (in miles) to the nearest service site operated by other health centers (health center award recipients or look-alikes)? [textbox]

        7.1 Is the proposed site located close (for example, within the same building, within 1 mile in an urban area, or within 5 miles in a rural area) to one or more service sites operated by another health center?
    • Yes
    • No

            7.1.1 If YES: Explain the rationale for locating the proposed site at that distance from another health center’s service site. [textbox] 

    8. Attach: 
        8.1 Current Service Area Map and Data Table: Select the “Service Area Competition” application map/table type in Health Center Program GeoCare Navigator. Make sure your map shows your health center’s current:
    • In-scope sites 
    • Service area ZIP Codes 
        8.2 Proposed Site Map and Data Table: Select the “Change in Scope” application map/table type in Health Center Program GeoCare Navigator. Make sure your map shows the:
    • Proposed site
    • ZIP Codes served by the proposed site

        ◦ The data tables must include at a minimum:
    • Low-Income Population (#)
    • Health Center Program: Penetration of Low-Income (%)
    • Health Center Program: Penetration of Total Population (%)
    • Dominant Health Center
    • Dominant Health Center Share of Patients (%)

[attachments – multiple, with at least two required]
				
    9. Is the current Health Center Program: Penetration of Total Population (%) for the proposed site greater than 50 percent?
    • Yes
    • No

        9.1 If YES: Explain the unmet need given the high penetration rate. [textbox]

    10. What is your health center’s projected number of patients (current and new patients) who will be served annually by the proposed site? [textbox]

        10.1 Is the projected number of patients fewer than 100?
    • Yes
    • No

10.1.1 If YES: Explain the low number of projected patients. [textbox] 

    11. Is the proposed site located in a ZIP Code outside of your health center’s current service area ZIP Codes?
    • Yes
    • No

        11.1 If YES, what is HRSA’s Unmet Need Score (UNS) of your health center’s current service area ZIP Codes? [textbox]

            11.1.1 Is the UNS Score 75 or above?
            ▪ Yes
            ▪ No

        11.2 If YES, what is the Health Center Program penetration of the low-income population in your health center’s current service area ZIP Codes? [textbox]

            11.2.1 Is the penetration of the low-income population 25 percent or lower?
            ▪ Yes
            ▪ No

        11.3 If YES to either 11.1.1 or 11.2.1: Given the unmet need in your health center’s current service area, explain why your health center is locating the site outside of its current service area. [textbox]

    12. What is HRSA’s Unmet Need Score (UNS) for the service area ZIP Codes that the proposed site will serve? [textbox]

        12.1  Is the UNS less than 75?
            ▪ Yes
            ▪ No
				
        12. 1.1 If YES: Provide justification for the proposed site given the UNS and any additional documentation of unmet need. [textbox]

[attachments – multiple, with all optional]

Note: For more information on Unmet Need Score, refer to the Unmet Need Score Map Tool and How We Know Which Areas Need Health Center Services webpages. 

    13. Briefly discuss how your health center chose the location type, hours of operation, and services to be offered at the proposed site:

        ◦ Location type (permanent, seasonal, mobile) [textbox] 
  
        ◦ Hours of operation (for example, part-time versus full-time, evening or weekend hours offered) [textbox]

        ◦ Types of services to be offered at the proposed site (for example, medical, dental, behavioral health) [textbox]

    14. How will individuals served through the proposed site have access to all in-scope services not available at the proposed site? Include information on how your health center helps patients access services. Explain how any transportation needs or travel barriers will be addressed.
[textbox]

    15. Will the proposed site provide only a limited set of services or a single service (for example, dental-only or behavioral health-only services)?
    • Yes
    • No

        15.1 If YES: Provide a rationale for why your health center decided to offer a limited set of services or a single service at the proposed site. [textbox]


    16. Will the proposed site serve only a subset of the patient population (for example, serve only women or only students at an elementary school)?
    • Yes
    • No

        16.1 If YES: What subset of the patient population will the proposed site serve? [textbox]

16.2  If YES: Provide a rationale for why your health center decided to serve that subset of the patient population at the proposed site.
[textbox]

16.3 If YES: If individuals who come to the proposed site for care are not part of the patient population served at the site, explain how your health center will assist those individuals to access care at another site operated by either your health center or another health center. Explain how such individuals will be referred to other health center sites for care and how any transportation needs or travel barriers will be addressed.
[textbox]

Coordination and Collaboration
In this section, you must address your health center’s efforts to coordinate and collaborate with each health center that is located in or serving the service area of the proposed site. This includes:
    • Any health centers identified in the “Description and Rationale” section of this CIS request that have service sites that are close to the proposed site (for example, within 1 mile in an urban area or within 5 miles in a rural area, or within the same building); and 
    • Any health centers identified as the dominant health center for a service area ZIP Code according to the GeoCare Navigator data tables you attached in the “Description and Rationale” section of this CIS request.

    17. Describe established or proposed coordination and collaboration efforts specific to this proposed site. Address how these efforts will specifically benefit the patient population to be served at the site.  [textbox]

        17.1 Does your health center have any documentation of these efforts?
            ▪ Yes
            ▪ No

17. 1.1 If YES: Attach the documentation of these efforts, including letters of support or agreements (for example, MOAs, MOUs, contracts).
[attachments – multiple, at least one required]

        17.2  If you are unable to get documentation from health centers, describe the outreach your health center made to these organizations about the proposed site and the result of this outreach. [textbox]

Co-Location
    18. Is the proposed site a school-based site?
    • Yes
    • No

    19. Is your health center’s proposed site co-located with another organization that provides health or other services (for example, the proposed site will be co-located within a hospital or behavioral health facility)?
    • Yes
    • No
        19.1 If YES: Explain, including describing the type of organization with which your health center’s proposed site will co-locate. [textbox]

    20. Will your health center’s governing board maintain full authority and control over the delivery of health services at the proposed site and operate the proposed site in compliance with all Health Center Program requirements?
Note: This includes compliance with all federal, state, or local legal requirements applicable to the particular co-location model, provided that such other requirements do not conflict with Health Center Program requirements. 

    • Yes
    • No

20.1 If NO: Explain. [textbox]

    21. Attach a floor plan of the proposed site, including its placement within the co-located facility.
[attachments – multiple, with at least one required]

    22. Attach the agreements for your health center’s proposed co-located site. For example, your health center’s contracts, memoranda of understanding (MOUs), or memoranda of agreement (MOAs) with applicable parties, and other relevant documents. 

The attachments must contain the complete agreements executed by all parties (for example, a signed paper copy, electronically-signed documents, or emails documenting acceptance). The attachments must include any additional documentation, such as appendices or addenda.

Within the attachments, clearly mark or highlight the proposed site address and the language that addresses each criterion. 

Provide the citation (for example, page numbers) for where each criterion is addressed in the attached documentation. You may provide additional narrative if necessary.

[attachments – multiple, with at least one required]

        22.1  How your health center will independently provide services or conduct activities at the co-located service site on behalf of your health center.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        22.2  How your health center will maintain separate clinical and fiscal operations from the co-located organization. This includes maintaining retrievable patient health records for health center patients.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        22.3  How your health center will maintain financial, billing, and audit records for its services performed at the proposed site.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

    23.  How will your health center inform patients at the proposed co-located site that they are receiving services from the health center? Provide details for each of the following:

        ◦ Posted signage at the proposed site [textbox]

        ◦ Information on the health center’s website [textbox]

        ◦ Directly informing patients verbally or with documentation that they are in a health center site and that they can access services regardless of their ability to pay [textbox]

        ◦ Another method [textbox]

School-Based Site
 
    24. Will your health center’s governing board maintain full authority and control over the delivery of health services at the proposed school-based site and operate the proposed school-based site in compliance with all Health Center Program requirements?
Note: This includes compliance with all federal, state, or local legal requirements applicable to the particular co-location model, including requirements for operating within a school location, provided that such other requirements do not conflict with Health Center Program requirements. 

    • Yes
    • No

        24.1 If YES or NO: Explain. [textbox] 

    25.  Delineate the roles and responsibilities of your health center from those of the school in the operation of the proposed school-based site. For example, describe any specific authorities or roles that the school or school board plays in the delivery of services. [textbox] 

    26. Describe how a patient will access the proposed school-based site and receive services. [textbox] 

    27. How will your health center inform patients, including parents and guardians where applicable, that they are receiving services from the health center? Provide details for each of the following:

        ◦ Posted signage at the proposed site [textbox]

        ◦ Information on the health center’s website [textbox]

        ◦ Directly informing patients verbally or with documentation that they are in a health center site and that they can access services regardless of their ability to pay [textbox]

        ◦ Another method [textbox]

    28. Attach a floor plan of the proposed site, including its placement within the school. [attachments – multiple, with at least one required]

    29. Attach your health center’s agreements with the school for the proposed school-based site and, if needed, other relevant documentation. 

The attachments must contain the complete agreements executed by all parties (for example, a signed paper copy, electronically-signed documents, or emails documenting acceptance). The attachments must include any additional documentation, such as appendices or addenda.

Within the attachments, clearly mark or highlight the proposed site address and the language that addresses each criterion. 

Provide the citation (for example, page numbers) for where each criterion is addressed in the attached documentation. You may provide additional narrative if necessary.

[attachments – multiple, with at least one required]

        29.1 How the Sliding Fee Discount Program (SFDP) requirements will apply at the proposed school-based site for all patients. 
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        29.2 How billing and collections requirements will be implemented for the proposed school-based site.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        29.3 How patients who use the proposed school-based site will have access to ALL of your health center’s in-scope services (both those services available and those services not available at the proposed school-based site).
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        29.4 How your health center will maintain separate clinical and fiscal operations from the school.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        29.5 How your health center will maintain a retrievable patient health record for each patient receiving services at the proposed school-based site.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        29.6 How your health center will maintain financial, billing, and audit records for its services performed at the proposed school-based site.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

Special Medically Underserved Populations

    30. Which Health Center Program funding or designation does your health center receive?

Select all that apply:
    • Residents of public housing under Section 330(i)
    • Homeless population under Section 330(h)
    • Migratory and seasonal agricultural workers under Section 330(g) 
    • Medically underserved populations under Section 330(e)
 
    31. Will the proposed site predominantly serve one or more of the special medically underserved populations for which your health center receives funding or designation?
    • Yes
    • No

        31.1 If YES: Which special medically underserved populations will the proposed site predominantly serve? Select all that apply:
    • Residents of Public Housing under Section 330(i)
    • Homeless Population under Section 330(h)
    • Migratory and Seasonal Agricultural Workers under Section 330(g) 

Residents of Public Housing under Section 330(i)

For the purposes of health centers receiving a Health Center Program award or designation under section 330(i) of the Public Health Service Act, public housing includes public housing agency-developed, owned, or assisted low-income housing, including mixed finance projects, but excludes housing units with no public housing agency support other than Section 8 housing vouchers.

(Section 330(i) of the PHS Act).

    32. Is the proposed site:
    • Located in public housing
    • Immediately accessible to public housing
Note: The term “Immediately accessible” means that the service site is within or adjacent to the public housing and that no physical barriers (for example, a highway or river) exist that prevent this medically underserved population from accessing the proposed service site.
    • None of the above – Document the specific public housing units or areas immediately accessible to public housing where individuals live who will be seen at the proposed site: [textbox]

Note: In the maps previously attached, ensure that the maps include all public housing that is:
    • Agency-developed low-income housing;
    • Agency-owned low-income housing; and
    • Agency-assisted low-income housing, including mixed finance projects.
Note: Exclude housing units that only receive Section 8 housing vouchers.

    33. How did your health center consult with the residents of public housing who will be served by the proposed site? [textbox]

    34. How will residents of public housing be involved in the planning and ongoing administration of the proposed site? [textbox]

Homeless Population under Section 330(h)

For the purposes of health centers receiving a Health Center Program award or designation under section 330(h) of the Public Health Service Act, the population served includes individuals:
    • Who lack housing (without regard to whether the individual is a member of a family);
    • Whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations;
    • Who reside in transitional housing; or
    • Who reside in permanent supportive housing or other housing programs that are targeted to homeless populations.

Note: A health center may continue to provide services for up to 12 months to formerly homeless individuals whom the health center has previously served but who are no longer homeless as a result of becoming a resident in permanent housing. A health center may also serve children and youth at risk of homelessness, homeless veterans, and veterans at risk of homelessness. 

(Section 330(h) of the PHS Act)

    35. Explain how the proposed site will serve homeless populations. Include specific examples of how the location and services of the proposed site will be responsive to the needs of this population. [textbox]

Migratory and Seasonal Agricultural Workers under Section 330(g)

For the purposes of health centers receiving a Health Center Program award or designation under section 330(g) of the Public Health Service Act, the population served includes:
    • Migratory agricultural workers who are individuals whose principal employment is in agriculture, who have been so employed within the last 24 months, and who establish for the purposes of such employment a temporary abode;
    • Seasonal agricultural workers who are individuals whose principal employment is in agriculture on a seasonal basis and who do not meet the definition of a migratory agricultural worker;
    • Individuals who are no longer employed in migratory or seasonal agriculture because of age or disability and who are within such catchment area; or
    • Family members of the individuals described above.
Agriculture refers to farming in all its branches, as defined by the North American Industry Classification System under codes 111, 112, 1151, and 1152.

(Section 330(g) of the PHS Act)

    36. Explain how the proposed site will serve migratory and seasonal agricultural workers. Include specific examples of how the location and services of the proposed site will be responsive to the needs of this population. [textbox]

Contractor-Operated Site

    37. Is the proposed site operated by a third-party organization on behalf of your health center through a written contractual agreement between your health center and the third-party organization? 
    • Yes
    • No


    38. Does your health center deliver General Primary Medical Care, at a minimum, directly through its own employees or volunteers (Form 5A: Services Provided should document General Primary Medical Care in Column I)?
    • Yes
    • No

38.1 If NO: Explain why your health center does not directly provide General Primary Medical Care. [textbox]

Note: HRSA may, at its discretion, evaluate such situations on a case-by-case basis to determine whether the circumstances justify an exception to this requirement.

    39. Does your health center directly operate at least one service site on your Form 5B: Sites?
    • Yes
    • No

39.1 If NO: Explain why your health center does not operate at least one service site directly. [textbox]

Note: HRSA may, at its discretion, evaluate such situations on a case-by-case basis to determine whether the circumstances justify an exception to this requirement.


    40. Specify whether your health center is contracting with a third-party organization for partial or full operation of the proposed site. [textbox]

    41. Provide the rationale for operating the proposed site through a contract (as opposed to your health center operating the proposed site directly). [textbox]

    42. Explain why this contractor was selected to operate the proposed site, including the contractor’s capabilities, resources, and experience with the health center patient population. [textbox]

    43. Did your health center use its procurement procedures for this contract?  
    • Yes
    • No

If NO: Explain: [textbox]

    44. Attach a copy of your health center’s contract with this contractor and, if needed, other documentation agreed to by both your health center and the contractor. 

The attachments must contain the complete  contract executed by all parties (for example, a signed paper copy, electronically-signed documents, or emails documenting acceptance). The attachments must include any additional documentation, such as appendices or addenda.

 Within the attachments, clearly mark or highlight the proposed site address and the language that addresses each criterion. 

Provide the citation (for example, page numbers) for where each criterion is addressed in the attached documentation. You may provide additional narrative if necessary.

[attachments – multiple, with at least one required]

44.1 How your health center’s sliding fee discount program will be applied to patients and how no patient will be denied services due to inability to pay, in accordance with your health center’s policies.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.2 How patients will be screened for sliding fee discount program eligibility based only on income and family size (for example, your health center will directly screen its patients for eligibility prior to the patient accessing services at the contractor-operated site).
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.3 How the contractor will ensure that its providers are licensed, certified, or registered as verified through a credentialing process, and in accordance with applicable federal, state, and local laws.
Note: The contract language can reference a more comprehensive process or policy. Credentialing for a contractor-operated site may happen in many ways. For example, the contractor has its own credentialing program, and the health center has reviewed that program for compliance.

Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.4 How the contractor will ensure that its providers are competent and fit to perform the contracted services, as assessed through a privileging process.
Note: The contract language can reference a more comprehensive process or policy. Privileging for a contractor-operated site may happen in many ways. For example, the contractor has its own privileging program, and the health center has reviewed that program for compliance.

Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.5 How your health center will access patient health records. The health center must have the right to access these records, but the health center does not need to be the record custodian.
Note: A health center with a contractor does not need to establish and maintain its own record of a patient seen by the contractor. However, the health center must have access to the contractor’s patient health records. HRSA will hold the award recipient accountable for the contractor’s compliance with the proper establishment and maintenance of health records.

Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.6 How the contractor will ensure the confidentiality of patient medical and billing records.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.7 How the contractor will ensure and assess the quality of patient care through its quality assurance programs.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.8 How the contractor will ensure that patients with Limited English Proficiency are able to access services (for example, your health center will provide the contractor with access to your health center’s language interpretation assistance services).
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.9 How the contractor will ensure that at least one person trained and certified in basic life support is present at the proposed site during regularly scheduled hours of operation.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.10 How the contractor demonstrates that it maintains professional and medical malpractice liability insurance for its personnel who provide services to the health center.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.11 How your health center’s governing board will retain its authority to approve the hours of operation and services provided at the proposed contracted site, evaluate the performance of the contractor in operating the proposed site (for example, based on quality assurance/quality improvement assessments), and take appropriate follow-up actions.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.12 How the contractor will maintain proper financial records and make the records accessible to your health center.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.13 How the contractor will provide data necessary to meet your health center’s applicable federal financial and programmatic reporting requirements.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

44.14 How the contractor will follow HHS grants requirements for record retention and access, audit, and property management.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

For more information on procurement standards, refer to 2 CFR Part 200.

Subrecipient-Operated Site

    45. Will the proposed site be operated by an organization (“subrecipient”) that:
    • Will receive section 330 award funding under a contract (a “subaward”) from your health center; and 
    • Demonstrates compliance with all of the requirements of section 330, including providing all required primary health services?
    • Yes
    • No


    46. Does your health center deliver General Primary Medical Care, at a minimum, directly through its own employees or volunteers (Form 5A: Services Provided should document General Primary Medical Care in Column I)?
    • Yes
    • No

46.1 If NO: Explain why your health center does not directly provide General Primary Medical Care. [textbox]

Note: HRSA may, at its discretion, evaluate such situations on a case-by-case basis to determine whether the circumstances justify an exception to this requirement.

    47. Does your health center directly operate at least one service site on your Form 5B: Sites?
    • Yes
    • No

47.1 If NO: Explain why your health center does not operate at least one service site directly. [textbox]

Note: HRSA may, at its discretion, evaluate such situations on a case-by-case basis to determine whether the circumstances justify an exception to this requirement.


    48. Provide the rationale for operating the proposed site through this subrecipient (as opposed to your health center operating the proposed site directly). [textbox]

    49. Explain why this subrecipient was selected to operate the proposed site, including the subrecipient’s capabilities, resources, and experience with the health center patient population. [textbox]

    50. Attach a copy of your health center’s agreement with this subrecipient and, if needed, other documentation agreed to by both your health center and the subrecipient. 

The attachments must contain the complete subaward agreement executed by all parties (for example, a signed paper copy, electronically-signed documents, or emails documenting acceptance). The attachments must include any additional documentation, such as appendices or addenda.

Within the attachments, clearly mark or highlight the proposed site address and the language that addresses each criterion. 

Provide the citation (for example, page numbers) for where each criterion is addressed in the attached documentation. You may provide additional narrative if necessary. 

[attachments – multiple, with at least one required]

50.1 How your health center’s governing board will retain its authority to approve the hours of operation and services provided at the proposed site, evaluate the performance of the subrecipient in operating the proposed site (for example, based on quality assurance/quality improvement assessments), and take appropriate follow-up actions.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

50.2 How your health center will access patient health records. 
Note: A health center with a subrecipient does not need to establish and maintain its own record of a patient seen by the subrecipient. However, the health center must have access to the subrecipient’s patient health records. HRSA will hold the award recipient accountable for the subrecipient’s compliance with the proper establishment and maintenance of health records.

Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

50.3 How the subrecipient will maintain proper financial records and make the records accessible to your health center.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

50.4 How the subrecipient will provide data necessary to meet your health center’s applicable federal financial and programmatic reporting requirements.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

50.5 How the subrecipient will follow HHS grants requirements for record retention and access, audit, and property management.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

50.6 What portion of the section 330 award funding the subrecipient will receive to operate the proposed site.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

    51. Discuss how your health center verified that this subrecipient meets all of the Health Center Program requirements applicable to your Health Center Program award. [textbox]

    52. How will your health center monitor that this subrecipient maintains compliance with all Health Center Program requirements and all other applicable requirements specified in your Health Center Program award? [textbox]



Reminder: If any information in this CIS request is incomplete, HRSA may disapprove this CIS request.
 


Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) are patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients and adjust fees based on income and family size. 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/2029. 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 1.5 hours 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or [email protected].  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.