Form 4 - Bureau of Primary Health Care
OMB No.: 0915-0285. Expiration Date: 9/30/2016DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Form 4: COMMUNITY CHARACTERISTICSFOR HRSA USE ONLYGrant NumberApplication Tracking NumberNote: The Service Area Percent and Target Population Percent will auto-calculate in EHB and can only be viewed on the read-only version of the form under Review Program Specific Forms in the left side menu.RaceService Area NumberService Area PercentTarget Population NumberTarget Population PercentNative HawaiianOther Pacific IslandersAsianBlack/African AmericanAmerican Indian/Alaska NativeWhiteMore than One RaceUnreported/Declined to Report (if applicable)Total: will auto-calculate in EHB100%100%Hispanic or Latino EthnicityService Area NumberService Area PercentTarget Population NumberTarget Population PercentHispanic or LatinoNon-Hispanic or LatinoUnreported/Declined to Report (if applicable)Total: will auto-calculate in EHB100%100%Income as a Percent of Poverty LevelService Area NumberService Area PercentTarget Population NumberTarget Population PercentBelow 100%100-199%200% and AboveUnknownTotal: will auto-calculate in EHB100%100%Primary Third Party Payment SourceService Area NumberService Area PercentTarget Population NumberTarget Population PercentMedicaidMedicareOther Public InsurancePrivate InsuranceNone/UninsuredTotal: will auto-calculate in EHB100%100%Special PopulationsService Area NumberService Area PercentTarget Population NumberTarget Population PercentMigratory/Seasonal Agricultural Workers and FamiliesHomelessResidents of Public HousingLesbian, Gay, Bisexual, and TransgenderHIV/AIDS-Infected PersonsPersons with Behavioral Health/Substance Abuse NeedsSchool Age ChildrenInfants Birth to 2 Years of AgeWomen Age 25-44Persons Age 65 and OlderOther Please Specify:______________Note: When completing Form 4 – Community Characteristics – please note that all information provided regarding race and/or ethnicity will be used only to ensure compliance with statutory and regulatory Governing Board requirements.?Data on race and/or ethnicity collected on this form will not be used as an awarding factor.Public Burden Statement: 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 project is 0915-0285. 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 Reports Clearance Officer, 5600 Fishers Lane, Room 10-29, Rockville, Maryland, 20857 ................
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