Other Requirements for Sites

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OMB No.: 0915-0285. Expiration Date: 6/30/2029
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration Other Requirements for Sites
FOR HRSA USE ONLY

Grant Number
Application
Tracking Number



Site Information
Name of Service Site

Site Address

1. Site Control and Federal Interest
1a. Identify current status of property site (If ‘Leased’, please answer Question 1b)
[_] Owned [_] Leased
1b. If Leased, please check the following:
[_] The applicant certifies the following:
    • The existing lease will provide reasonable control of the project site.
    • The existing lease is consistent with the proposed scope of project.
    • We understand and accept the terms and conditions regarding federal interest in the property.
2. Cultural Resource Assessment and Historic Preservation Considerations
2a. Was the project facility constructed prior to 1975?
[_] Yes [_] No
2b. Is the project facility 50 years or older?
[_] Yes [_] No
2c. Does any element of the overall work at the project site include:
    • Any renovation/modifications to the exterior of the facility (e.g., roof, HVAC, windows, siding, signage, exterior painting, generators) or
    • Ground disturbance activity (e.g., expansion of building footprint, installation or expansion parking lot, sidewalks, utilities)?
[_] Yes [_] No
2d. Does the project involve renovation to a facility that is, or near a facility that is, architecturally, historically, or culturally significant?
[_] Yes [_] No
2e. Is the site located on or near Native American, Alaskan Native, Native Hawaiian, or equivalent culturally significant lands?
[_] Yes [_] No
Attachments
Property Information (required) (Maximum 1)
Provide a copy of the title, deed, or lease for the property.
Landlord Letter of Consent (as applicable) (Maximum 1)
If property status is ‘Leased’, applicant must provide Landlord Letter of Consent.
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 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.