FY19 IBHS Application Forms

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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 Overview Form
FOR HRSA USE ONLY

Grant Number
Application Tracking Number



Project Work Plan Section (include or hide as applicable to the NOFO)
Project Work Plan
    • See the NOFO instructions to determine requirements.
    • Describe as many activities as necessary to fully outline your project work plan.
    • The project work plan should include activities over the period of performance.
Objective 
Focus Area
    • TBD (objectives aligned with particular funding opportunity)
        ◦ TBD (bullets based on each objective)

    • TBD (focus area aligned with particular funding opportunity)
        ◦ TBD (bullets based on each focus area)

Service Category Examples
Activity Category Examples
Activity Subcategory Examples
Activity Description/
Time Frame/
Key Action Step(s)/
Key Person Responsible
Activity Progress Update (for NCC work plan only)
    • General Primary Medical Care
    • Mental Health
    • Substance use disorder
    • Oral health
    • Vision
    • Enabling
    • Increasing Workforce Capacity
    • Recruit and onboard personnel (direct hire and/or contracted)


      
      
    • Conduct training and professional development


      
      
    • Expand care delivery workflows, including new or enhanced referral arrangements


      
      
    • Expand use of telehealth


      
      
    • Provide in-person services


      
      
    • Other: Please specify
(Up to 125 characters with spaces)



    • Increasing Organizational Capacity
    • Enhance telehealth infrastructure and integration


      
      
    • Enhance health information technology 


      
      
    • Purchase equipment and supplies


      
      
    • Other: Please specify
(Up to 125 characters with spaces)



    • Enhancing Physical Infrastructure
    • Add new site(s) (permanent or seasonal)


      
      
    • Add mobile unit(s)


      
      
    • Minor alteration/renovation (A/R)


      
      
    • Other: Please specify
(Up to 125 characters with spaces)



Other: Please specify
    • Other: Please specify
(Up to 125 characters with spaces)



Activities List Section (include or hide as applicable to the NOFO)
Work Plan Activity List
    • Select at least two activities, but no more than five, for each focus area.
    • You must provide a description of the activity if you select “other” (up to 300 characters, including spaces). 
    • In the Activity Selection Rationale field for each activity, describe how the activity addresses an unmet need or barrier.
Activity 1 TBD (aligned with particular funding opportunity)
    • Example TBD (examples aligned with Activity 1)
    • Example TBD (examples aligned with Activity 1)

Activity 2 TBD (aligned with particular funding opportunity)
    • Example TBD (examples aligned with Activity 2)
    • Example TBD (examples aligned with Activity 2)

Activity 3 TBD (aligned with particular funding opportunity)
    • Example TBD (examples aligned with Activity 3)
    • Example TBD (examples aligned with Activity 3)

Activity 4 TBD (aligned with particular funding opportunity)
    • Example TBD (examples aligned with Activity 4)
    • Example TBD (examples aligned with Activity 4)

Scope Section (include or hide as applicable to the NOFO)


Patient Estimate Section (include or hide as applicable to the NOFO)
New Patient Estimate
Enter the number of estimated unduplicated new patients your health center will
serve in calendar year 20## (patients who will be new to the health center) as
a result of your project.
Note: This number may be added to your H80 patient target if your funding continues beyond the period of performance.

Enter the number of estimated [specify service type based on NOFO] patients your health center will serve in calendar year 20##.

Enter the number of estimated [specify service type based on NOFO] patients your health center will serve in calendar year 20##.

Assistance with Accessing Needed Follow-Up Services
Enter your estimated number of [children and their families] that will be assisted with accessing appropriate follow-up services within 30 days.


Site Hours Section (include or hide as applicable to the NOFO)
Instructions
    • The sites in the summary table below are those you selected on the Form 5B Select Site(s) From Scope page.
    • If you need to add or remove a site, use the Form 5B Select Site(s) From Scope page to make changes.
    • Sites referenced in your Project Narrative should match the sites listed below.
    • Click on the [Update] link under Actions for each site to complete Site Information questions.
    • Below the summary table, respond to questions about services that will be provided during your additional hours.
A. Site Summary Table




A1. Name of Service Delivery Site




A2. Service Delivery Site Address

A3. According to Form 5B at the time of NOFO
release, this site is open this many hours per week:
A4. How many additional hours (not counting the number in A3) are you proposing this site will be open per week as a result of EH
funding?

A5. The new Total Hours of Operation (A3 + A4) for this site per week as a result of EH funding will be:





Actions
(Data from Form 5B: Select Site(s)
from Scope)
(Data from Form 5B: Select Site(s)
from Scope)
(Data from Form 5B: Select Site(s)
from Scope)



Update
(Data from Form 5B: Select Site(s)
from Scope)
(Data from Form 5B: Select Site(s)
from Scope)
(Data from Form 5B: Select Site(s)
from Scope)



Update
B. Briefly describe your plan for increasing hours. Include a timeline for key tasks/deliverables, including how many hours you plan to add within the first 6 months of award.
(Response can be up to 3,000 characters with spaces, approximately 500 words)

C. What in-scope services, listed in Form 5A: Services Provided, will be available during your additional hours of operation?
At least one response must be Yes.
C1. Medical
Yes □
No □

C2. Dental
Yes □
No □

C3. Mental Health
Yes □
No □
C4. Substance Use Disorder
Yes □
No □

C5. Vision
Yes □
No □
C6. Enabling
Yes □
No □

C7. Pharmacy
Yes □
No □
Note: You can use EH funding to change the way a service is offered, but you cannot start providing services that are NOT currently offered (for which no column is currently selected on Form 5A: Services Provided).

Topic Expertise Section (include or hide as applicable to the NOFO)

Funding Request Verification Section (include or hide as applicable to the NOFO)

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.