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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Resources and Services Administration

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New Access Point Program-Specific Forms

Technical Assistance Conference Calls 

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Form 1A: General Information Worksheet (PDF - 68KB) (Word - 73KB)

Form 1B: BPHC Funding Request Summary (PDF - 46 KB)

Form 1C: Documents on File (PDF -37 KB) (Word - 46KB)

Form 2: Staffing Profile (PDF - 104 KB) (Word - 58KB)

Form 3: Income Analysis (PDF -197 KB) (Word - 102KB)

Form 4: Community Characteristics (PDF - 81 KB) (Word - 83KB)

Form 5A: Services Provided (PDF - 81 KB) (Word - 121KB)

Form 5B: Service Sites (PDF - 43 KB) (Word - 51KB)

Form 5C: Other Activities/Locations (If Applicable) (PDF - 35 KB) (Word - 37KB)

Form 6A: Current Board Member Characteristics (PDF - 50 KB) (Word - 55KB)

Form 6B: Request for Waiver of Governance Requirements (If Applicable) (PDF - 32 KB) (Word - 37KB)

Form 8: Health Center Affiliation Certification and Health Center Affiliation Checklist (If Applicable) (PDF - 56 KB) (Word - 63KB)

Form 9: Need for Assistance (NFA) Worksheet (PDF - 52 KB) (Word - 105KB)

Form 10:  Annual Emergency Preparedness and Management Report (PDF - 68 KB) (Word - 49KB)

Form 12: Organization Contacts (PDF - 38 KB) (Word - 47KB)

424C Budget Information-Construction Programs (PDF - 40 KB) (Word - 48KB)

Other New Access Point Program-Specific Information

Electronic Health Record (EHR) (PDF - 22 KB)

EHR Readiness Checklist (PDF -35 KB)

Environmental Information and Documentation (EID) (PDF - 68 KB )

Other Requirements for Sites (PDF - 29 KB)

Clinical Performance Measures (Word - 126KB)

Financial Performance Measures (Word - 89KB) 

Consolidated Performance Measures (Word - 49KB) (PDF - 31KB)

Performance Measures Samples (Word - 62KB) (PDF - 46KB)