Form 43 Project Qualification Criteria

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

PROJECT QUALIFICATION CRITERIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration PROJECT QUALIFICATION CRITERIA	FOR HRSA USE ONLY
	Application Tracking Number	Grant Number
	Project Number	Project Type
	Project Title

Qualification Criteria

1. Has the applicant organization received construction-related funding (i.e. new construction or alteration/renovation/repair project) through FY 2009 Facility Investment Program or FY 2011 Capital Development funding?

[_] Yes  [_] No  

If ‘Yes’ please provide the description:

2. Does the project proposed occur at a site that received construction-related funding (i.e. new construction or alteration/renovation/repair project) through FY 2009 Capital Improvement Program?

[_] Yes  [_] No  

If ‘Yes’ please provide the description:

3. Have any construction contracts for the proposed project been executed (entered into a formal contract)?

[_] Yes  [_] No  

If ‘Yes’ please provide the description:

4. Has any construction work (including demolition) been implemented for the proposed project?

[_] Yes  [_] No  

If ‘Yes’ please provide the description:

5. Will the space proposed to be improved or enhanced with Federal funds be rented to other entities for purposes of generating revenue?

[_] Yes  [_] No  

If ‘Yes’ please provide the description:

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.