Providers: $25.5 billion in Provider Relief Fund & American Rescue Plan rural funding is now available. Submit your application by October 26, 2021.

Forms for Service Area Competition

Service Area Competition Program-Specific Forms

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

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)

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

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

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

Other Service Area Competition Program-Specific Information

SAC FY 2011 Application Deadlines (Word - 58KB)

Health Center Program Definitions (Word - 77KB)

Data Resources Guide (PDF - 334 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)

Electronic Health Record (Word - 47KB)

Date Last Reviewed:  April 2017


Cheri Daly, public health analyst
HRSA Office of Policy and Program Development
301-594-4300 |

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HRSA Electronic Submission User Guide (PDF - 278 KB)