Equipment List Form.pdf

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Equipment List (AS APPLICABLE) - Continued Equipment List (AS APPLICABLE) - Continued OMB No.: 0915-0285. Expiration Date: 06/30/2029 OMB No.: 0915-0285. Expiration Date: 06/30/2029

FOR HRSA USE ONLY

FOR HRSA USE ONLY

DEPARTMENT OF HEALTH AND HUMAN SERVICES

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration Health Resources and Services Administration Grant Number Grant Number Application Tracking Number Application Tracking Number Equipment List (AS APPLICABLE) Equipment List (AS APPLICABLE) Instructions Instructions Equipment costs entered here should be consistent with those provided in the Budget Narrative and SF-424A Budget Information Form. Equipment means tangible personal property (including information technology systems) having a useful life of more than one year and a per-unit acquisition cost which equals or exceeds $10,000. Equipment that does not meet the $10,000 threshold should be considered supplies and should not be entered on this form.

Equipment costs entered here should be consistent with those provided in the Budget Narrative and SF-424A Budget Information Form. Equipment means tangible personal property (including information technology systems) having a useful life of more than one year and a per-unit acquisition cost which equals or exceeds $10,000. Equipment that does not meet the $10,000 threshold should be considered supplies and should not be entered on this form.

List of Equipment List of Equipment Type Type Description Description Unit Price Unit Price Quantity Quantity Total Price Total Price Type (required) Type

TOTAL

TOTAL

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) are patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients and adjust fees based on income and family size. 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0285 and it is valid until 06/30/2029. 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or paperwork@hrsa.gov. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

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