Form 8: Health Center Agreements

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

Form 8: Health Center Agreements
OMB No.: 0915-0285. Expiration Date: 06/30/2029 
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
FORM 8: HEALTH CENTER AGREEMENTS
FOR HRSA USE ONLY

Grant Number
Application Tracking Number



Note: If a Health Center Program award recipient wishes to enter into an agreement/arrangement post-award that will either (1) result in another organization carrying out a substantial portion of the approved scope of project or (2) impact the governing board’s composition, authorities, functions, or responsibilities, a Prior Approval request must be submitted and approved by HRSA before the agreement/arrangement can be formalized and implemented.
Part I: Health Center Agreements
    1. Does your organization have a parent, affiliate, or subsidiary organization?
If Yes, indicate the number of each agreement by type in 1a, 1b, or 1c below and complete Part II. If No, Part II is Not Applicable.
Yes	 No

1a. Number of Parent Organizations

1b. Number of Affiliate Organizations

1c. Number of Subsidiary Organizations

Total Number of Parent, Affiliate, or Subsidiary Organizations

    2. Do you currently have, or plan to utilize
a) 	Contract(s) with another organization to perform substantive programmatic work within the proposed scope of project? For the purposes of the Health Center Program, contracting for substantive programmatic work applies to contracting with a single entity for the majority of health care providers.
Or
b) 	Subawards to carry out a portion of the proposed scope of project. The purpose of a subaward is to carry out a portion of the Federal award and creates a Federal assistance relationship with the subrecipient.
NOTE: Subawards or contracts made to related organizations such as a parent, affiliate, or subsidiary, must be identified and addressed in this form. The acquisition of supplies, material, equipment, or general support services (e.g., janitorial services, contracts with individual providers) is not considered programmatic work.
If Yes, indicate the number of each agreement by type in 2a and/or 2b below and complete Part II. If No, Part II is Not Applicable.
Yes	 No
2a. 	Number of contracts with another organization to perform substantive programmatic work within the proposed scope of project.

2b. 	Number of subawards made to subrecipients to carry out a portion of the proposed scope of project.

2c. 	Total number of contracts for substantive programmatic work and/or subawards.


Part II: Attachments
All parent, affiliate, or subsidiary agreements, as well as contracts for substantive programmatic work and subawards, including contracts or subawards which involve a parent, affiliate, or subsidiary organization referenced in Part I, must be uploaded in full. Uploaded documents will NOT count against the page limit.
Parent/Affiliate/Subsidiary/Contract/Subawardee Organization Name 
(maximum 50 characters)

Type of Agreement
Parent
Affiliate
Subsidiary
Subaward
Contract
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 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 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 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.