Minor AR Project Cover Page Form.pdf

OMB No.: 0915-0285. Expiration Date: 06/30/2029

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

MINOR ALTERATION/RENOVATION (A/R)

PROJECT COVER PAGE

FOR HRSA USE ONLY

Grant

Number Application

Tracking Number

1. Site Information

Name of Service Site Site Address

Improved Project Square Footage

2. Project Description

Provide a detailed description of the scope of work of the minor A/R project. Identify the major clinical and non-clinical spaces that will result from or be improved by the project.

List key improvements, such as permanently affixed equipment to be installed; modifications and repairs to the building exterior (including windows); HVAC modifications (including the installation of climate control and duct work); electrical upgrades; and plumbing work.

Describe how potential adverse impacts on the environment will be minimized. Indicate whether, and if so, how the project will implement green/sustainable design practices/principles (e.g., using project materials, design/renovation strategies).

Maximum 4,000 characters counting spaces:

3. Project Management/Resources/Capabilities

Provide a detailed description of the scope of work of the minor A/R project. Identify the major clinical and non-clinical spaces that will result from or be improved by the project.

List key improvements, such as permanently affixed equipment to be installed; modifications and repairs to the building exterior (including windows); HVAC modifications (including the installation of climate control and duct work); electrical upgrades; and plumbing work.

Describe how potential adverse impacts on the environment will be minimized. Indicate whether, and if so, how the project will implement green/sustainable design practices/principles (e.g., using project materials, design/renovation strategies)

Maximum 4,000 characters counting spaces:

4. Is the proposed minor alteration/renovation project part of a larger scale renovation, construction, or expansion project?

Yes No (If yes, provide details in the Project Description.)

Provide the following documents related to this site under the indicated application attachment in the

NOFO:

1. Minor A/R Project Budget Justification (required) (Maximum 1)

2. Environmental Information Documentation (EID) Checklist (required) (Maximum 1)

3. Floor Plans/Schematic Drawings (required) (Maximum 2)

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.

https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim mailto:paperwork@hrsa.gov https://www.hrsa.gov/about/508-resources

Instructions

An allowable minor A/R project is a stand-alone project in an existing facility. Minor A/R may include work required to:

Install fixed equipment or other items such as windows, HVAC, signs in or on the existing building, or lighting;

Modernize, improve, and/or reconfigure the interior of a facility;

Repair and/or replace the exterior;

Improve accessibility such as curb cuts, ramps, or widening doorways; and/or Address safety requirements and concerns.

A minor A/R project cannot increase the total square footage of an existing building or require ground disturbance. For example, you cannot create a new parking lot or expand a building footprint.

Complete the Minor A/R Project Cover Page for each site where minor A/R will occur.

1. Site Information Enter the site name and address from the last Form 5B you submitted to HRSA.

Enter the total square feet of the area to be altered/renovated in the Improved Project

Square Footage field.

2. Project Description (Maximum 4,000 characters including spaces) Provide a detailed description of the scope of work of the minor A/R project. Identify the major clinical and non-clinical spaces that will result from or be improved by the project.

List key improvements, such as permanently affixed equipment to be installed;

modifications and repairs to the building exterior (including windows); HVAC modifications (including the installation of climate control and duct work); electrical upgrades; and plumbing work.

Describe how potential adverse impacts on the environment will be minimized. Indicate whether, and if so, how the project will implement green/sustainable design practices/principles (e.g., using project materials, design/renovation strategies).

3. Project Management (Maximum 4,000 characters including spaces) Explain the oversight for the minor A/R project, including the Project Manager and the

Project Team, if applicable, responsible for managing the project.

Describe how the Project Team has the expertise and experience necessary to successfully manage and complete the project within the timeframe and achieve the goals and objectives established for this project.

4. Is the proposed minor alteration/renovation project part of a larger scale renovation, construction, or expansion project?

Select “no” to certify that the proposed project is a stand-alone project and includes only minor A/R costs. Select “yes” if the proposed project is part of a larger renovation, construction, or expansion project and explain in the Project Description. Your project may be unallowable if you answer yes.

5. Project Budget Justification Provide budget justification for the minor A/R project in the indicated application attachment in the NOFO. Describe each cost in detail and explain how the costs support the project’s purpose. Clearly identify other funding sources needed to support the minor A/R project and whether you have already secured these funds. Also provide a distinct timeline that shows when you will start and complete the proposed minor A/R activities, including the number of months each key activity will take.

See the TA webpage for a sample A/R Budget Justification, including sample allowable and unallowable costs. Refer to the cost principles in 2 CFR Part 200 for details on allowable costs.

6. Environmental Information and Documentation (EID) Checklist A template of the EID checklist is available on the TA webpage for you to download, complete, and upload, to the indicated application attachment in the NOFO.

The National Environmental Policy Act of 1969 (NEPA), the National Historic Preservation Act (NHPA), and other associated laws require that we consider the environmental impacts and potential effects on historical and archeological resources of any A/R or construction projects supported with federal funds. You will submit a completed EID Checklist for the site where you request to use federal funds for minor A/R. You must explain each response of “yes” on the EID Checklist.

If funded, you must receive HRSA approval before starting your minor A/R project. You can only work on the design and permitting stage of the project until any required environmental and historic preservation reviews are completed and related conditions of award are lifted. To get approval, you may need to provide extra documentation such as a hazardous materials survey, abatement plans, or NHPA Section 106 consultation. For more information, see the Environmental and Historic Preservation TA webpage.

7. Floor Plans/Schematic Drawings/Site Plan The floor plans/schematic drawings/site plan should be uploaded to the indicated application attachment in the NOFO. Provide line drawings for your minor A/R project that:

Include a scale and the linear dimensions for each room.

Clearly show the work described in the project description and budget justification.

Indicate the location of the proposed renovation area in the existing building Distinguish improved space from unaffected space.

Note the total net and gross square footage of space to be renovated, and any changes or additions to existing mechanical and electrical systems.

Provide an overall site plan (or key plan) that shows the location of the project within the overall facility and shows any exterior improvements included for the project.

https://bphc.hrsa.gov/funding/funding-opportunities/capital-development-grants/environmental-historic-preservation-technical-assistance https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200