32E 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 nce. Select all that apply. If you select “other evidence-based strategy,” you must complete the “Other Evidence-Based Strategy(ies)” section below.implement and/or advayou funding will help Expanded Servicesthat evidence-based integration strategy(ies) the	Select All That Apply
Medication-Assisted Treatment HYPERLINK "https://www.integration.samhsa.gov/clinical-practice/mat/mat-overview"	□
Collaborative Care Model HYPERLINK "https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/get-trained/about-collaborative-care"	□
Patient-Centered Medical Home HYPERLINK "http://www.pcpcc.org/resource/behavioral-health-integration-pcmh"	□
Medicaid Health Homes HYPERLINK "https://www.medicaid.gov/medicaid/ltss/health-homes/index.html"	□
Four Quadrant Model HYPERLINK "https://www.integration.samhsa.gov/resource/four-quadrant-model"	□
Assertive Community Treatment HYPERLINK "https://www.centerforebp.case.edu/practices/act"	□
Integration of Mental Health, Substance Use, and Primary Care Services HYPERLINK "https://www.integration.samhsa.gov/sliders/slider_10.3.pdf"	□
Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) HYPERLINK "http://impact-uw.org/about/research.html"	□
Screening, Brief Interventions, Referral to Treatment (SBIRT) HYPERLINK "https://www.samhsa.gov/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 senovationAlterations/R
Are you proposing to use funding for minor alteration/renovation (A/R) that will support services?the expanded If yes, HRSA will request additional information about your minor A/R plans separately after 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).Expanded Services awards are announced. Expanded Services			Select One Option
Yesproposal includes minor A/R costs, and I acknowledge that the A/R activities may not begin until HRSA approves our A/R plans Expanded Services, my health center’s			□
Noproposal does not include minor A/R costs Expanded Services, my health center’s			□
Scope of Services
Review ervices are on your Form 5A?S Expandedd changes to cope Adjustment or Change in Scope request be necessary to ensure that all planne Will a S.Form 5A: Services Providedyour current approved Access the technical assistance materials on the 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).Scope of Project resource website HYPERLINK "https://bphc.hrsa.gov/programrequirements/scope.html"

2018 Uniform Data System Manual HYPERLINK "https://bphc.hrsa.gov/sites/default/files/bphc/datareporting/reporting/2018-uds-reporting-manual.pdf"

paperwork@hrsa.gov HYPERLINK "https://sharepoint.hrsa.gov/sites/bphc/oppd/ED1/OMB%20Forms%20Approval%202020/paperwork@hrsa.gov" 42 U.S.C. 254b HYPERLINK "http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim"