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 5C: OTHER ACTIVITIES/LOCATIONS
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FOR HRSA USE ONLY
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Application Tracking
Number
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Grant Number
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ACTIVITY/LOCATION
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| *Type of Activity
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| *Description of Activity
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| *Frequency of Activity
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| *Type of Location(s) where Activity is Conducted
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ACTIVITY/LOCATION
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Type of Activity
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Description of Activity
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Frequency of Activity
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Type of Location(s) where Activity is Conducted
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ACTIVITY/LOCATION
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Type of Activity
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Description of Activity
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Frequency of Activity
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Type of Location(s) where Activity is Conducted
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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 10-33, Rockville, Maryland, 20857.
