OMB Number: 0906-0032
Expiration Date: xx/xx/202x
(This application is illustrative and the actual application may appear differently in HRSA’s Electronic Handbooks (EHBs) System)
Department of Health and Human Services Health Resources and Services Administration |
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OMB# |
Award Recipient Name |
Grant Number |
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Contact Information |
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CONTACT INFORMATION (Include an honorific (Ms., Mrs., Mr., Dr., etc.) before the name) All fields marked with an * are required. |
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EXECUTIVE DIRECTOR (Must electronically sign and certify the volunteer health professional sponsorship application prior to submission)
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ublic 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. Congress, through enactment of Section 9025 of the 21st Century Cures Act (Pub. L. 114-255), which added subsection 224(q) to the Public Health Service Act (42 U.S.C. § 233(q)), extended liability protections for the performance of medical, surgical, dental, and related functions to Volunteer Health Professionals (VHP) at health centers that have also been deemed as employees of the Public Health Service (PHS). These forms provide HRSA with the information essential for application evaluation and determination of whether an individual VHP meets the statutory requirements for deemed PHS employee status for the purposes of FTCA coverage. The OMB control number for this information collection is 0906-0032 and it is valid through 10/31/2020. 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 2 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 Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.
Section I. Sponsoring Health Center Acknowledgments of Deemed Status Requirements |
[ ] Yes [ ] No
[ ] Yes [ ] No
application, the materials submitted as part of its initial entity FTCA deeming or redeeming application and the entity’s Notice of Deeming Action will be utilized by HRSA in determining that the entity is eligible to sponsor health center volunteers for deemed PHS employee status. [ ] Yes [ ] No |
Section II. Volunteer Health Professional: Acknowledgment of Required Performance Conditions (Responses Required) |
For each of the individual VHP listed in Section III below, the sponsoring health center acknowledges its understanding that, for a volunteer to be considered a VHP, the following requirements must be met: |
1. The services provided by the VHP occur at the sponsoring health center’s facilities (i.e., at its approved service sites) or through offsite programs or events carried out by the sponsoring health center (section 224(q)(2)(A)). |
[ ] Yes |
2. The VHP does not receive any compensation for the service from the individual, the sponsoring health center, or any third-party payer (including reimbursement under any insurance policy, health plan, or federal or state health benefits program); except that the VHP may receive repayment from the sponsoring health center for reasonable expenses incurred by the VHP in the provision of the service to the individual, which may include travel expenses to or from the site of services (section 224(q)(2)(C)). |
[ ] Yes |
3. Before the service is provided, the VHP or the sponsoring deemed health center posts a clear and conspicuous notice at the site where the service is provided of the extent to which the legal liability of the health care practitioner is limited pursuant to the Public Health Service Act (section 224(q)(2)(D)). |
[ ] Yes |
4. At the time the service(s) is provided, the VHP(s) is licensed or certified in accordance with applicable federal and state laws regarding the provision of the service(s) (section 224(q)(2)(E)). |
[ ] Yes |
5. The sponsoring health center maintains all relevant documentation certifying that the volunteer meets the requirements to be considered a VHP (section 224(q)(2)(F)). |
[ ] Yes |
The sponsoring health center acknowledges its understanding that for each VHP the following is required: |
6. Before the service is provided, the sponsoring health center must credential and privilege the VHP(s) in accordance with all current Health Center Program and FTCA Program credentialing and privileging requirements and maintain this information in a file for each VHP (section 224(q)(3)). |
[ ] Yes |
Section III. Volunteers Sponsored for Deeming |
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For each Volunteer Health Professional sponsored for deeming, provide the following information.
(Note 1: Do NOT include on this listing individuals who are not volunteer health professionals, such as employees, contractors, governing board members and officers.)
(Note 2: Do NOT include on this listing individuals who are trainees (i.e., students, interns, or residents) conducting duties as part of a residency program. These individuals are not eligible for deemed PHS employment through the VHP Program.) |
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Add Individual Details*
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Contact Information
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Section III. Volunteers Sponsored for Deeming |
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Is this volunteer a COVID-19 vaccination volunteer who will be volunteering solely to administer COVID-19 vaccinations?
[] Yes [] No
Roles and Specialty
[Upload a signed volunteer agreement for each individually named volunteer that clearly states that the sponsored health professional is a volunteer of the health center, outlines the terms and conditions of the services that the volunteer will provide, acknowledges that the health professional will not receive any compensation including reimbursement from any third party payor, and documents each off-site program or event where the health professional will provide services.]
Note: For volunteers that are solely administering CVOID-19 vaccines, the volunteer agreement should clearly include that information and should also any other state or federal requirements that must be met for the individual to volunteer as a COVID-19 vaccinator.
Please estimate, how many hours on average will the volunteer work per month?
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Credentialing and Privileging
(Each sponsored VHP must be credentialed and privileged by the health center in accordance with the Health Center Program Compliance Manual, Chapter 5.) |
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Licensure and/or Certification
Each sponsored VHP is required to be licensed or certified in accordance with applicable Federal and State laws to perform the services that are requested. [Note: If the answer is No, this volunteer is not eligible for coverage under the Health Center Volunteer Health Professional Program, and should not be included in this application.]
Or
For VHPs that are solely administering COVID-19 Vaccines, the individual is operating under a state or federal legislation, declaration, or exemption that permits the VHP to administer COVID-19 vaccinations under a special grant of authority due to the ongoing COVID-19 pandemic. [ ] Yes [ ] No
Please upload one of the following:
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Section III. Volunteers Sponsored for Deeming |
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Medical Malpractice History
[ ] Yes [ ] No
If yes, provide a list of the claims or actions. For each claim or action, include:
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*Notes:
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Section IV. Signatures |
Certification and Signature |
I, (Executive Director)*, certify that, to the best of my knowledge and belief,
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*The application must be signed by the Executive Director, as indicated in Section I. Contact Information. |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Calendar Year 2020 Volunteer Health Professional Federal Tort Claims Act (FTCA) Deeming Sponsorship Application Instructions |
Subject | Calendar Year 2020 Volunteer Health Professional Federal Tort Claims Act (FTCA) Deeming Sponsorship Application Instructions |
Author | HRSA |
File Modified | 0000-00-00 |
File Created | 2021-04-12 |