Document
Form 5B: Sites
ICR 202610-0915-001 · OMB 0915-0285 · Object 174055200.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Form 5B: Sites |
| Last Modified By | Writer |
| File Modified | 2026-09-30 |
| File Created | 2026-10-22 |
| Conversion State | complete |
Extracted Text
Form 5B: Sites OMB No.: 0915-0285. Expiration Date: 06/30/2029 DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 5B: SITES FOR HRSA USE ONLY Grant Number Application Tracking Number Site Qualification Criteria Is the site a Domestic Violence (Confidential) shelter? Select Yes for this question only if the site being added is a confidential site serving victims of domestic violence and the site address cannot be published due to the necessity to protect the location of the domestic violence shelter. Yes No Not Applicable Site Information Site Name Physical Site Address (Ensure your address contains the unique suite, building, or other notation, if appropriate. If the address displayed does not contain this information, select Change Physical Location and update as needed.) Site Type Service Site Other Site Transitional Care in Carceral Setting Site Web URL Site Phone Number Location Type Permanent Seasonal Mobile Service Site Setting Freestanding Co-located with Hospital Co-located with School Co-located with Behavioral Health Organization Co-located with another organization Co-located with a Domestic Violence Shelter Other Site Setting Administrative Patient Support Services – No Visits Generated Pharmacy – No Visits Generated Date Site was Added to Scope (mm/dd/yyyy) (HRSA will populate this field. It is the date of HRSA approval for the addition of this site.) Read-only for sites already in scope and disabled when adding a new site Site Operational Date (mm/dd/yyyy) (HRSA will populate this field. It is the date this site is open and operational. Your health center will document this through a scope verification submission.) CMS Certification Number (CCN) Status This site is neither permanent nor seasonal per CMS (i.e., does not require unique CCN) Health center does not/will not bill under the FQHC Medicare system at this site Number is pending; application for this site has been submitted to CMS Application for this site has not yet been submitted to CMS This site has a CCN CCN (Required if ‘This site has a CCN’ is selected in 'CMS Certification Number (CCN) Status' field) FQHC Site National Provider Identification (NPI) Number (Optional field) Total Hours of Operation (Hours per week when the site is open and providing in-person services or a combination of in-person and telehealth services; do not include hours when providing only telehealth services.) Months of Operation Service Area Zip Codes Site Operated by Health Center/Applicant Subrecipient Contractor Subrecipient or Contractor Information (Required only if 'Subrecipient’ or ‘Contractor' is selected in 'Site Operated By' field) Subrecipient/Contractor Organization Name Subrecipient/Contractor Organization Physical Site Address Subrecipient/Contractor EIN 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/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 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.