Form 22 Form 5C - Clean

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Form 5C: OTHER ACTIVITIES/LOCATIONS		FOR HRSA USE ONLY
		Grant Number	Application Tracking Number
Activity/Location Information
Type of Activity (select one)	[_] Immunizations [_] Hospital Admitting [_] Medical Rounds [_] Home Visits [_] Health Fairs [_] Non-Clinical Outreach [_] Portable Clinical Care [_] Health Education [_] Other – Please Specify:
Frequency of Activity (max 600 characters)
Description of Activity (max 600 characters)
Type of Location(s) where Activity is Conducted

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 30 minutes 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.