Attachment B

Attachment B

Public Health Service Impact Statement

Attachment B

Form Approved

OMB No. 0990-0317

PUBLIC HEALTH SYSTEM IMPACT STATEMENT

Public Health Service (PHS) awarding components that award health services grants to community-based, nongovernmental organizations require applicants under covered programs to send a copy of the application face page (SF 424, Application for Federal Assistance) and a one-page summary of the project, called the Public Health System Impact Statement (PHSIS), to the appropriate State and/or local health agencies, as determined by the applicant.

The PHSIS is to be not more than one page in length and is to address the extent to which a proposed project affects and is related to existing community services. The PHSIS should include the following information, which may be taken from the application’s Program Narrative:

 a description of the population to be served whose needs would be met under the proposal;

 a summary of the services to be provided; and

 a description of any coordination planned with the appropriate State or local health agency(ies).

A copy of the PHSIS and SF 424 application face page must be mailed to the head of the appropriate State and local health agencies in the area to be impacted no later than the Federal application receipt due date.

Public reporting burden for gathering, duplicating, and mailing of the Public Health System Impact Statement is estimated to be 10 minutes. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to HHS Reports Clearance Officer, 200 Independence Ave SW, Room 537-H, Washington, DC 20201. ATTN: PRA (0990-0317). Do not send the completed form to this address.