Form 3 OSV Acknowledgement Form

Salesforce Survey

The Salesforce survey will enable HCs to acknowledge receipt of the notice of OSV, confirm project director/contact information, and allow the HC to submit a BPHC contact form inquiry to discuss the details of their OSV.

Survey – all questions are required unless otherwise indicated

Introduction:

Your organization has been identified for a fiscal year 2024 Operational Site Visit (OSV). Please use this survey to acknowledge your OSV, including the dates and type, and to provide updated contact information for this OSV, if necessary.

Q1a Please select your Health Center’s state from the dropdown.

[STATE]

Q1b Please select your Health Center Program awardee number from the dropdown.

[awardee number]

[Pre-populate organization name based on number selected above]

Q2 I acknowledge my Operational Site Visit, including the type of visit and the dates of the visit as documented through the email sent on [DATE].

• I acknowledge my Operational Site Visit type and dates as indicated.

Q3 Please enter your organization’s contact person(s) information for this Operational Site Visit.

• [CONTACT NAME] [OPTIONAL CONTACT NAME]

• [CONTACT EMAIL] [OPTIONAL CONTACT EMAIL]

• [CONTACT PHONE NUMBER] [OPTIONAL CONTACT PHONE NUMBER]

Q4 (optional) If you have any questions or concerns regarding your Operational Site Visit, please submit an inquiry including the details of your concern and your awardee number through the BPHC Contact Form and provide the ticket number.

• [TICKET NUMBER]