Other Requirements for Sites Form.pdf

OMB No.: 0915-0285. Expiration Date: 6/30/2029

DEPARTMENT OF HEALTH AND HUMAN

SERVICES

Health Resources and Services Administration

Other Requirements For Sites

FOR HRSA USE ONLY

Grant Number Application

Tracking Number

Site Information Name of Service Site Site Address

1. Site Control and Federal Interest 1a. Identify current status of property site (If ‘Leased’, please answer Question 1b)

Owned Leased 1b. If Leased, please check the following:

The applicant certifies the following:

The existing lease will provide the health center reasonable control of the project site.

The existing lease is consistent with the proposed scope of project.

We understand and accept the terms and conditions regarding federal interest in the property.

2. Cultural Resource Assessment and Historic Preservation Considerations 2a. Was the project facility constructed prior to 1975?

Yes No 2b. Is the project facility 50 years or older?

Yes No 2c. Does any element of the overall work at the project site include:

Any renovation/modifications to the exterior of the facility (e.g., roof, HVAC, windows, siding, signage, exterior painting, generators) or

Ground disturbance activity (e.g., expansion of building footprint, installation or expansion parking lot, sidewalks, utilities)?

Yes No 2d. Does the project involve renovation to a facility that is, or near a facility that is, architecturally, historically, or culturally significant?

Yes No 2e. Is the site located on or near Native American, Alaskan Native, Native Hawaiian, or equivalent culturally significant lands?

Yes No

Property Information (required) (Maximum 1) Provide a copy of the title, deed, or lease for the property.

Landlord Letter of Consent (as applicable) (Maximum 1) If property status is ‘Leased’, applicant must provide Landlord Letter of Consent.

Attachments:

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

Complete this form for each site where minor A/R activities will occur.

1. Site Control and Federal Interest If you own the site, select “owned.” If you do not own the site, select “leased,” even if you do not pay a fee to use the property.

If the site is leased, certify that:

The existing lease will provide you reasonable control of the project site for at least 5 years after the renovation is completed.

The existing lease is consistent with the proposed scope of project.

You understand and accept the terms and conditions regarding federal interest in the property (summarized below).

The federal government has a reversionary interest in property that is constructed, acquired, or improved with federal funds. The federal interest is based on the federal share of the total allowable project costs (excluding movable equipment), as a percent of the value of the property after the project is completed.

Federal interest exists for the useful life of the funded minor A/R activities. Since new construction and major A/R projects with a total cost of $1,000,000 or more are not allowable under this award, you are not required to file a Notice of Federal Interest (NFI). However, if you receive an award and draw down funds, you acknowledge that the federal interest exists, even though you are not required to file a NFI. You must maintain documentation to track and protect the federal interest. Documentation includes communications between the lessor and the lessee related to protecting such interest.

2. Cultural Resource Assessment and Historic Preservation Considerations Respond to each of the questions in this section.

3.

Provide a copy of the title, deed, or lease for the property.

If you are proposing a minor A/R project at a site you do not own, you must provide a

Landlord Letter of Consent.

◦ This document must include the property owner’s agreement to the proposed minor

A/R and recognition of the federal interest.

◦ Both the owner and applicant must sign it.

◦ This attachment is required if you propose a minor A/R project at a site provided “in-kind” (i.e., at no charge).

◦ You can use this Landlord Letter of Consent (PDF) as a template.

Attachments:

https://bphc.hrsa.gov/sites/default/files/bphc/funding/lloc-minorrenovation.pdf