Document
Form 5A: Services Provided
ICR 202610-0915-001 · OMB 0915-0285 · Object 174055100.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Form 5A: Services Provided |
| Last Modified By | Writer |
| File Modified | 2026-09-30 |
| File Created | 2026-10-22 |
| Conversion State | complete |
Extracted Text
OMB No.: 0915-0285. Expiration Date: 6/30/2029
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
FORM 5A: SERVICES PROVIDED (REQUIRED SERVICES)
FOR HRSA USE ONLY
Grant Number
Application Tracking #
This form will pre-populate for competing continuation applicants. For more information, refer to the Service Descriptors for Form 5A: Services Provided and the Column Descriptors for Form 5A: Services Provided.
Service Type
Service Delivery Methods
Column I: Direct
Column II: Contracts and Subawards
Column III: Cooperative Arrangements
General Primary Medical Care
Diagnostic Laboratory
Diagnostic Radiology
Screenings
Coverage for Emergencies During and After Hours
Voluntary Family Planning
Immunizations
Well Child Services
Gynecological Care
Obstetrical Care
• Prenatal Care
• Intrapartum Care (Labor & Delivery)
• Postpartum Care
Preventive Dental
Pharmaceutical Services
Homeless Population (HP) Substance Use Disorder Services (required only for HP Funding/Designation)
Case Management
Eligibility Assistance
Health Education
Outreach
Transportation
Translation
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
FORM 5A: SERVICES PROVIDED (ADDITIONAL SERVICES)
FOR HRSA USE ONLY
Grant Number
Application Tracking Number
Service Type
Service Delivery Methods
Column I: Direct
Column II: Contracts and Subawards
Column III: Cooperative Arrangements
Additional Dental Services
Behavioral Health Services
• Mental Health Services
• Substance Use Disorder Services
Optometry
Recuperative Care Program Services
Environmental Health Services
Occupational Therapy
Physical Therapy
Speech-Language Pathology/Therapy
Nutrition
Complementary and Alternative Medicine
Additional Patient Support Services
Public Burden Statement: 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/202X. 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 0.25 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.