OMB No.: 0915-0285. Expiration
Date: 08/31/2010
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
FORM 5A: SERVICES PROVIDED
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FOR HRSA USE ONLY |
| Application Tracking Number |
Grant Number |
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SERVICE TYPE |
MODE OF SERVICE PROVISION
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STATUS |
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APPLICANT |
AGREEMENT
(Grantee pays for service) |
REFERRAL ARRANGEMENTS
(Grantee DOES NOT pay) |
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Required Services |
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Clinical Services |
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General Primary Medical Care |
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Diagnostic Laboratory |
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Diagnostic X-Ray |
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Screenings |
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· Cancer |
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· Communicable Diseases |
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· Cholesterol |
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· Blood lead test for elevated
blood lead level |
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· Pediatric vision, hearing
and dental |
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Emergency Medical Services |
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Voluntary Family Planning |
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Immunizations |
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Well-Child Services |
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Gynecological Care |
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Obstetrical Care |
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Prenatal and Prenatal Services |
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Preventive Dental |
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Referral to Mental Health1 |
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Referral to Substance1 |
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Referral to Specialty Services |
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Pharmacy |
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Substance Abuse services (required for HCH programs): |
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· Detoxification |
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· Outpatient Treatment |
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· Residential Treatment |
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· Rehabilitation (non hospital
settings) |
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Non - Clinical Services |
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Case Management |
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· Counseling/Assessment |
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· Referral |
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· Follow-up/Discharge Planning |
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· Eligibility Assistance |
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Health Education |
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Outreach |
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Transportation |
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Translation2 |
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Substance abuse services (required for HCH programs): |
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· Harm/Risk Reduction (e.g.
educational materials, nicotine gum/patches) |
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Additional Services (Optional) |
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Clinical Services |
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Urgent Medical Care |
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Dental Services |
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· Restorative |
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· Emergency |
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Mental Health Services |
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· Treatment/Counseling |
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· Developmental Screening |
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· 24-Hour Crisis |
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Substance Abuse Services |
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Recuperative Care |
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Environmental Health Services |
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Occupational-Related Health Services3 |
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· Screening for Infectious
Diseases |
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· Injury Prevention Programs |
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Occupational Therapy |
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Physical Therapy |
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HIV Testing |
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TB Therapy |
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Podiatry |
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Rehabilitation (Non-Hospital Settings) |
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Other: |
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Non Clinical Services |
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WIC |
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Nutrition (not WIC) |
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Child Care |
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Housing Assistance |
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Employment/Education Counseling |
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Food Bank/Meals |
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Other: |
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1.
Applicants
are required to provide mental health and substance
abuse services by referral arrangement. However,
applicants may provide these services by applicant
or agreement instead of by referral arrangement.
2.
Required
for Health Centers serving a substantial number
of patients with limited English-Proficiency.
3.
Additional Services for Health Centers serving Migrant
and seasonal farm workers (MSFWs).
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
.5 hours 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 10-33, Rockville, Maryland, 20857.
