Form 1C: Documents on File

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Form 1C: Documents On File
OMB No.: 0915-0285. Expiration Date: 06/30/2029
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
FORM 1C: DOCUMENTS ON FILE
FOR HRSA USE ONLY

Grant Number
Application 
Tracking Number



Note: Date of Last Review/Revision must use the date format of mm/dd/yyyy. This listing does not include all policy/procedure documents required to be maintained on file. Records demonstrating implementation of required policies and procedures must also be available for review.

Management and Finance
Date of Last Review/Revision 
(mm/dd/yyyy)
Not Applicable
(N/A)
Personnel policies, including selection and dismissal procedures, salary and benefit scales, employee grievance procedures, 
and equal opportunity practices.

N/A
Policies/procedures consistent with E.O. 
14273 and terms of awards to make insulin 
and injectable epinephrine available at or 
below the discounted price paid by the health center awardee or sub-awardee under the 
340B Drug Pricing Program (plus a minimal administration fee) to individuals with low incomes who: (a) have a high cost-sharing requirement for either insulin or injectable epinephrine; (b) have a high unmet deductible; or (c) have no health care insurance. For this purpose, “a low-income individual” means an individual living in a household with an income level at or below 200 percent of the Federal Poverty Guidelines.


Procurement procedures.

N/A
Standards of Conduct/Conflict of Interest policies/procedures.

N/A
Financial Management/Accounting and Internal Control policies and/or procedures to ensure awarded Health Center Program federal funds are not expended for restricted activities.

N/A
Financial Management/Accounting and Internal Control policies/procedures related to restrictions on the use of federal funds for the purchase of sterile needles or syringes for the hypodermic injection of any illegal drug.1


Management and Finance
Date of Last Review/Revision 
(mm/dd/yyyy)
Not Applicable
(N/A)
Financial Management/Accounting and Internal Control policies/procedures related to restrictions on the use of federal funds to provide abortion services, except in cases of rape or incest or where there is a threat to the life of the mother.2 (Only applicable if your organization provides abortion services; otherwise, indicate as N/A.)


Billing and Collections policies/procedures, including those regarding waivers or fee reductions and refusal to pay.

N/A
Services
Date of Last Review/Revision 
(mm/dd/yyyy)
Not Applicable
(N/A)
Credentialing/Privileging operating procedures.

N/A
Coverage for Medical Emergencies During and After Hours operating procedures.

N/A
Continuity of Care/Hospital Admitting 
operating procedures.

N/A
Sliding Fee Discount Program policies, operating procedures, and sliding fee schedule.

N/A
Quality Improvement/Assurance Program policies and operating procedures that address clinical services and management, patient safety, and confidentiality of patient records.

N/A
Governance
Date of Last Review/Revision 
(mm/dd/yyyy)
Not Applicable
(N/A)
Governing Board Bylaws.

N/A
Co-Applicant Agreement (Only applicable to public agency health centers; otherwise, indicate as N/A.)


Evidence of Nonprofit or Public Agency Status.

N/A
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 06/30/2029. 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 0.5 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.