Project Cover Page

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

Grant Number
Application Tracking Number



    1. Site Information
Name of Service Site

Site Address

Improved Project Square Footage

    2. Project Description
    • Provide a detailed description of the scope of work of the project. Identify the major clinical and non-clinical spaces that will result from or be improved by the project.  
    • List key improvements, such as permanently affixed equipment to be installed; modifications and repairs to the building exterior (including windows); HVAC modifications (including the installation of climate control and duct work); electrical upgrades; and plumbing work.  
Maximum 4,000 characters counting spaces: 
    3. Project Management/Resources/Capabilities
    • Explain the oversight for the project, including the Project Manager and the Project Team, if applicable, responsible for managing the project.  
    • Describe how the Project Team has the expertise and experience necessary to successfully manage and complete the project within the timeframe and achieve the goals and objectives established for this project.  
Maximum 4,000 characters counting spaces:
    4.  Is the proposed minor alteration/renovation project part of a larger scale renovation, construction, or expansion project?  
Yes [_]  No [_]
Attachments:
Provide following documents related to this site:
    1. Budget Justification (required) (Maximum 1 document)
    2. Environmental Information Documentation (EID) Checklist (required) (Maximum 1 document) 
    3. Floor Plans/Schematic Drawings (required) (Maximum 2 documents)
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 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.