Form 23 Form 6A - Clean

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX
DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 6A: CURRENT BOARD MEMBER CHARACTERISTICS	FOR HRSA USE ONLY
	Grant Number	Application Tracking Number
Note: The list of Board Members will pre-populate for competing continuation and competing supplement applicants.

Name

Current Board Office Position Held

Area of Expertise

>10% of Income from Health Industry

Health Center Patient

Live or Work in Service Area

Special Population Representative

(If yes, specify Special Population)

PATIENT BOARD MEMBER CLASSIFICATION

Gender

Number of Patient Board Members

Male

Female

Unreported/Declined to Report

Ethnicity

Number of Patient Board Members

Hispanic or Latino

Non-Hispanic or Latino

Unreported/Declined to Report

Race

Number of Patient Board Members

Native Hawaiian

Other Pacific Islanders

Asian

Black/African American

American Indian/Alaska Native

White

More Than One Race

Unreported/Declined to Report

Note: This section is ONLY required if you selected Public (non-Tribal or Urban Indian) as the Business Entity on Form 1A of this application. In all other cases, select N/A.

If the applicant is a public organization/center, do the board members listed above represent a co-applicant board?

Yes

No

N/A

If yes, ensure that the co-applicant agreement is included as Attachment 6 in the Appendices form of this application.

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.