Chapter 3: Needs Assessment |
- PN Need section
- Form 1A: General Information Worksheet
- Form 4: Community Characteristics
- Form 5B: Service Sites
- Attachment 1: Service Area Map and Table
- Attachment 12: Other Relevant Documents
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Chapter 4: Required and Additional Health Services |
- PN Response section
- Project Overview Form
- Form 5A: Services Provided
- Attachment 7: Summary of Contracts and Agreements
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Chapter 5: Clinical Staffing |
- PN Response section
- Project Overview Form
- Form 1C: Documents on File
- Form 2: Staffing Profile
- Form 8: Health Center Agreements
- Attachment 7: Summary of Contracts and Agreements
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Chapter 6: Accessible Locations and Hours of Operation |
- PN Response section
- Project Overview Form
- Form 5B: Service Sites
- Form 5C: Other Activities/Locations
- Attachment 1: Service Area Map and Table
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Chapter 7: Coverage for Medical Emergencies During and After Hours |
- Project Overview Form
- Form 1C: Documents on File
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Chapter 8: Continuity of Care and Hospital Admitting |
- PN Response section
- Project Overview Form
- Form 1C: Documents on File
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Chapter 9: Sliding Fee Discount Program |
- PN Response section
- Project Overview Form
- Form 1C: Documents on File
- Attachment 8: Sliding Fee Discount Schedule(s)
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Chapter 10: Quality Improvement/Assurance |
- PN Impact section
- Project Overview Form
- Form 1C: Documents on File
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Chapter 11: Key Management Staff |
- PN Resources/Capabilities section
- Project Overview Form
- Form 2: Staffing Profile
- Form 12: Organization Contacts
- Attachment 3: Project Organizational Chart
- Attachment 4: Position Descriptions for Key Management Staff
- Attachment 5: Biographical Sketches for Key Management Staff
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Chapter 12: Contracts and Subawards |
- PN Resource/Capabilities section
- Project Overview Form
- Budget Narrative
- Form 8: Health Center Agreements
- Attachment 7: Summary of Contracts and Agreements
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Chapter 13: Conflict of Interest |
- PN Resources/Capabilities section
- Project Overview Form
- Form 1C: Documents on File
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Chapter 14: Collaborative Relationships |
- PN Collaboration section
- Attachment 1: Service Area Map and Table
- Attachment 9: Collaboration Documentation
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Chapter 15: Financial Management and Accounting Systems |
- PN Resources/Capabilities section
- Project Overview Form
- Form 1C: Documents on File
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Chapter 16: Billing and Collections |
- PN Resources/Capabilities section
- Project Overview Form
- Form 1C: Documents on File
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Chapter 17: Budget |
- PN Support Requested section
- SF-424A: Budget Information Form
- Budget Narrative and Personnel Table
- Form 1B: Funding Request Summary
- Form 3: Income Analysis
- Equipment List
- Alteration/Renovation Budget Justification
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Chapter 18: Program Monitoring and Data Reporting Systems |
- PN Impact section
- Project Overview Form
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Chapter 19: Board Authority |
- PN Resources/Capabilities and Governance sections
- Project Overview Form
- Form 1C: Documents on File
- Form 8: Health Center Agreements
- Attachment 2: Bylaws
- Attachment 3: Project Organizational Chart
- Attachment 6: Co-Applicant Agreement
- Attachment 10: Articles of Incorporation
- Attachment 11: Evidence of Non-profit or Public Agency Status
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Chapter 20: Board Composition |
- PN Governance section
- Project Overview Form
- Form 4: Community Characteristics
- Form 6A: Board Member Characteristics
- Form 6B: Request for Waiver of Board Member Requirements
- Attachment 2: Bylaws
- Attachment 6: Co-applicant Agreement
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