SAC/SAC-AA Application Attachments

The following table presents a summary of attachment-related information from Section IV.2.vi of the notice of funding opportunity (NOFO) for easy reference. Refer to the NOFO for details related to each attachment.

Applications that do not include attachments marked “C” (required for completeness) will be considered incomplete or non-responsive and will not be considered for funding. Failure to include attachments marked “R” (required for review) may negatively impact the objective review score.

Note: Attachments that will be assessed for determining compliance with the Health Center Program requirements are denoted with a bolded, underlined asterisk.

Attachment Required for Completeness (C) or Review (R) Instructions Counted in Page Limit (Y/N)
Attachment 1: Service Area Map and Table R Upload a map of the service area for the proposed project, indicating the organization’s proposed health center site(s) listed in Form 5B: Service Sites. The map must clearly indicate the proposed service area zip codes, any medically underserved areas (MUAs) and/or medically underserved populations (MUPs), and Health Center Program award recipients, look-alikes, and other health care providers serving the proposed zip codes. Maps should be created using UDS Mapper HRSA BPHC exit disclaimer. Markers may need to be manually placed for the locations of other major private provider groups serving low income/uninsured patients.
Include a corresponding table that lists each zip code tabulation area (ZCTA) in the service area; the number of Health Center Program award recipients and look-alikes serving each ZCTA; the dominant award recipient serving each ZCTA; total population; total low-income population; total Health Center Program award recipient patients; and low-income population and total population penetration levels for each ZCTA and for the overall proposed service area. This table will be automatically created in UDS Mapper. See the SAC Technical Assistance webpage or the SAC-AA Technical Assistance webpage, as applicable, for samples and instructions on creating maps using UDS Mapper. For a tutorial, see the UDS Mapper website HRSA BPHC exit disclaimer.
Y
*Attachment 2: Bylaws R Upload (in its entirety) the applicant organization’s most recent bylaws. Bylaws must be signed and dated indicating review and approval by the governing board. Public centers that have a co-applicant must submit the co-applicant governing board bylaws. See the GOVERNANCE section of the Project Narrative for more details. Y
*Attachment 3: Project Organizational Chart R Upload a one-page document that depicts the applicant’s current organizational structure, including the governing board, key personnel, staffing, and any subrecipients or affiliated organizations. Y
*Attachment 4: Position Descriptions for Key Management Staff R Upload current position descriptions for key management staff: project director (PD)/chief executive officer (CEO), clinical director (CD), chief financial officer (CFO), chief information officer (CIO), and chief operating officer (COO). Indicate on the position descriptions if key management positions are combined and/or part time (e.g., CFO and COO roles are shared). Each position description should be limited to one page and must include, at a minimum, training and experience, qualifications, duties, and functions. Y
Attachment 5: Biographical Sketches for Key Management Staff R Upload current biographical sketches for key management staff: PD/CEO, CD, CFO, CIO, and COO. Identify if the individual will fill more than one key management position. Biographical sketches should not exceed two pages each. When applicable, biographical sketches must include training, language fluency, and experience working with the cultural and linguistically diverse populations to be served.  
*Attachment 6: Co-Applicant Agreement
(as applicable)
  • New: C
  • Competing Continuation and Competing Supplement: R
Public center applicants that have a co-applicant board must submit, in its entirety, the formal co-applicant agreement signed by both the co-applicant governing board and the public center. See the RESOURCES/CAPABILITIES and GOVERNANCE sections of the Project Narrative for more details. N
Attachment 7: Summary of Contracts and Agreements (as applicable) R Upload a BRIEF SUMMARY describing all current or proposed patient service-related contracts and agreements, consistent with Form 5A: Services Provided, Columns II and III, respectively.  The summary must address the following items for each contract or agreement:
  • Name of contract/referral organization.
  • Type of contract or agreement (e.g., contract, referral agreement, Memorandum of Understanding or Agreement).
  • Brief description of the type of services provided and how/where services are provided.
  • Timeframe for each contract or agreement (e.g., ongoing contractual relationship, specific duration).

If a contract or agreement will be attached to Form 8: Health Center Agreements (e.g., subrecipient agreement; contract or subaward to a parent, affiliate, or subsidiary organization), denote this with an asterisk (*). Contracts for substantive programmatic work and subrecipient agreements must be included in Form 8.

Y
*Attachment 8: Articles of Incorporation
(as applicable)
  • New: R
  • Competing Continuation and Competing Supplement: N/A
New applicants:  Upload the official signatory page (seal page) of the organization’s Articles of Incorporation. A public center with a co-applicant must upload the co-applicant’s Articles of Incorporation signatory page, if incorporated. A Tribal organization must reference its designation in the Federally Recognized Indian Tribe List maintained by the Bureau of Indian Affairs. Y
*Attachment 9: Collaboration Documentation R Upload current dated documentation of collaboration activities to provide evidence of commitment to the project. See the COLLABORATION section of the Project Narrative for details on required documentation. Letters of support should be addressed to the organization’s board, CEO, or other appropriate key management staff member (e.g., clinical director).

Note: Reviewers will only consider letters of support and other documentation of collaboration submitted with the application.

Y
*Attachment 10: Sliding Fee Discount Schedule(s) R Upload the current sliding fee discount schedule(s). See the RESPONSE section of the Project Narrative for details. Y
Attachment 11: Evidence of Nonprofit or Public Center Status
  • New: C
  • Competing Continuation and Competing Supplement: R
Applicants must upload evidence of nonprofit or public center status. This attachment does not count toward the page limit.

Private Nonprofit: A private, nonprofit organization must submit any one of the following as evidence of its nonprofit status:

  • A copy of a currently valid Internal Revenue Service (IRS) tax exemption letter/certificate.
  • A statement from a state taxing body, state attorney general, or other appropriate state official certifying that the applicant organization has a nonprofit status and that none of the net earnings accrue to any private shareholders or individuals.
  • A certified copy of the organization’s certificate of incorporation or similar document (e.g., Articles of Incorporation) showing the state or tribal seal that clearly establishes the nonprofit status of the organization.
  • Any of the above documentation for a state or local office of a national parent organization, and a statement signed by the parent organization that the applicant organization is a local nonprofit affiliate.

Public Agency Organization: Public Agency applicants must provide documentation demonstrating that the organization qualifies as a public agency (e.g., state or local health department). Any of the following is acceptable:

  • A current dated letter affirming the organization’s status as a state, territory, county, city, or municipal government; a health department organized at the state, territory, county, city, or municipal level; or a subdivision or municipality of a United States (U.S.) affiliated sovereign State (e.g., Republic of Palau).
  • A copy of the law that created the organization and that grants one or more sovereign powers (e.g., the power to tax, eminent domain, police power) to the organization (e.g., a public hospital district).
  • A ruling from the State Attorney General affirming the legal status of an entity as either a political subdivision or instrumentality of the State (e.g., a public university).
  • A “letter ruling” which provides a positive written determination by the IRS of the organization’s exempt status as an instrumentality under Internal Revenue Code section 115.

Tribal or Urban Indian Organizations, as defined under the Indian Self-Determination Act or the Indian Health Care Improvement Act, must provide documentation of such status.

N
Attachment 12: Operational Plan (as applicable) • New and Competing Supplement: R
• Competing Continuation: N/A
New and competing supplement applicants must upload the Operational Plan. Refer to the SAC Technical Assistance webpage for detailed instructions or the SAC-AA Technical Assistance webpage, as applicable, for a sample. Y
Attachment 13: Other Relevant Documents (as applicable) R Applicants must upload an indirect cost rate agreement if such costs are claimed. If desired, include other relevant documents to support the proposed project (e.g., charts, organizational brochures, lease agreements). Maximum of two uploads. 

New and competing supplement applicants must include lease/intent to lease documentation in this attachment if a proposed site is or will be leased.

Y

 

Date Last Reviewed:  June 2020