Form 32 Health Center Program Supplemental Information - Clean.d

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration HEALTH CENTER PROGRAM: SUPPLEMENTAL INFORMATION FORM	FOR HRSA USE ONLY
	Grant Number	Application Tracking Number

Evidence-Based Strategies
Identify the evidence-based integration strategy(ies) that Expanded Services funding will help you implement and/or advance. Select all that apply. If you select “other evidence-based strategy,” you must complete the “Other Evidence-Based Strategy(ies)” section below.	Select All That Apply
Medication-Assisted Treatment	□
Collaborative Care Model	□
Patient-Centered Medical Home	□
Medicaid Health Homes	□
Four Quadrant Model	□
Assertive Community Treatment (ACT)	□
Integration of Mental Health, Substance Use, and Primary Care Services	□
Improving Mood-Promoting Access to Collaborative Treatment (IMPACT)	□
Screening, Brief Interventions, Referral to Treatment (SBIRT)	□
Other evidence-based strategy(ies)	□
Other Evidence-Based Strategy(ies)
If you selected “other evidence-based strategy(ies)” above, provide the strategy name and a publicly available URL demonstrating evidence that each other strategy identified is effective for its intended purpose. If your strategy includes multiple components, provide the name of the broader, overall strategy. If you plan to implement/advance more than three “other” strategies, include their information in an attachment.
Strategy name:
Reference:
Strategy name:
Reference:
Strategy name:
Reference:

Minor Alterations/Renovations
Are you proposing to use funding for minor alteration/renovation (A/R) that will support the expanded services? If yes, HRSA will request additional information about your minor A/R plans separately after Expanded Services awards are announced. Expanded Services funds requested for minor A/R may not be obligated until required information is submitted and HRSA approves your A/R plans (6 to 9 months post award).	Select One Option
Yes, my health center’s Expanded Services proposal includes minor A/R costs, and I acknowledge that the A/R activities may not begin until HRSA approves our A/R plans	□
No, my health center’s Expanded Services proposal does not include minor A/R costs	□
Scope of Services
Review your current approved Form 5A: Services Provided. Will a Scope Adjustment or Change in Scope request be necessary to ensure that all planned changes to Expanded Services are on your Form 5A? Access the technical assistance materials on the Scope of Project resource website for guidance in determining whether a Scope Adjustment or Change in Scope will be necessary (click on the “Services” header in the Resources section to access the Form 5A information). If yes, you must separately submit a Scope Adjustment or Change in Scope request to HRSA. You may not modify your approved Form 5A through this application.	Select One Option
Yes, I reviewed my Form 5A and determined that my health center’s proposed activities will require a Scope Adjustment or Change in Scope request to modify Form 5A	□
No, I reviewed my Form 5A and determined that my health center’s proposed activities will not require a Scope Adjustment or Change in Scope request to modify Form 5A	□
If yes, describe the proposed changes and a timeline for requesting necessary modifications to your Form 5A below (Up to 1,000 characters counting spaces)

Staffing Impact
You must propose to increase at least 0.5 personnel FTE within 8 months of award. These personnel increases must be reported on progress reports and reflected in your 2020 annual Uniform Data System (UDS) report. Refer to the 2018 Uniform Data System Manual for staffing position definitions.
Staffing Positions by Major Service Category
	New Direct Hire Staff FTEs Proposed	New Contractor FTEs Proposed
Psychiatrists
Licensed Clinical Psychologists
Licensed Clinical Social Workers
Other Licensed Mental Health Providers (e.g., psychiatric social workers, psychiatric nurse practitioners, family therapists) Please Specify: [open text box]
Other Mental Health Staff (e.g., “certified” individuals who provide counseling, treatment, or support to mental health providers) Please Specify: [open text box]
Substance Use Disorder Providers
Family Physicians
General Practitioners
Internist
Obstetrician/Gynecologist
Pediatricians
Other Specialty Physicians and Sub-Specialists (e.g., Emergency Medicine, Addiction Medicine, Pain Medicine, Infectious Disease) Please Specify: [open text box]
Nurse Practitioners
Physician Assistants
Certified Nurse Midwives
Nurses
Other Medical Personnel (e.g., Medical Assistants, Nurse Aides)
Laboratory Personnel
Pharmacy Personnel
Case Managers
Patient/Community Education Specialists
Outreach Workers
Transportation Staff
Eligibility Assistance Workers
Interpretation Staff
Community Health Workers
Other Enabling Services Staff (e.g., staff who support outreach, care coordination, transportation) Please Specify: [open text box]
Other Professional Health Services Staff (e.g., physical therapists, occupational therapists, acupuncturists) Please Specify: [open text box]
Subtotal	[Total calculated by EHB]	[Total calculated by EHB]
Total FTEs	[year 1 total calculated by EHB]

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. 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. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. 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 Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.