0285-9 Need for Assistance

OMB No.: 0915-0285. Expiration Date: 08/31/2010

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 9 – NEED FOR ASSISTANCE WORKSHEET	FOR HRSA USE ONLY
	Grant Number	Application Tracking Number

SECTION I: CORE BARRIERS

Population to One FTE Primary Care Physician Ratio
Data Response	(Ratio)	Year to which data apply
Data Source
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

Percent of Population at or Below 200 percent of poverty
Data Response	(%)	Year to which data apply
Data Source
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

Percent of Population Uninsured
Data Response	(%)	Year to which data apply
Data Source	:
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

Distance (miles) OR travel time (minutes) to nearest primary care provider accepting new Medicaid patients and/or uninsured patients
Data Response		Year to which data apply
Data Source
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

SECTION II: CORE HEALTH INDICATORE

Diabetes
Core Health Indicator
National Benchmark (Required, if Health Indicator selected is ‘Other’)
Data Response		Year to which data apply
Data Source
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

Cardiovascular Disease
Core Health Indicator
National Benchmark (Required, if Health Indicator selected is ‘Other’)
Data Response		Year to which data apply
Data Source
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

Cancer
Core Health Indicator
National Benchmark (Required, if Health Indicator selected is ‘Other’)
Data Response		Year or date to which data apply
Data Source
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

Prenatal and Perinatal Health
Core Health Indicator
National Benchmark (Required, if Health Indicator selected is ‘Other’)
Data Response		Year or date to which data apply
Data Source
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

Child Health
Core Health Indicator
National Benchmark (Required, if Health Indicator selected is ‘Other’)
Data Response		Year or date to which data apply
Data Source
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

Behavioral and Oral Health
Core Health Indicator
National Benchmark (Required, if Health Indicator selected is ‘Other’)
Data Response		Year or date to which data apply
Data Source
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

SECTION III: OTHER HEALTH INDICATORE

Indicator#1
Health Indicator
National Benchmark (Required, if Health Indicator selected is ‘Other’)
Data Response		Year to which data apply
Data Source
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

Indicator# 2
Health Indicator
National Benchmark (Required, if Health Indicator selected is ‘Other’)
Data Response		Year to which data apply
Data Source
Methodology Utilized/Data Source Description/Other
Identify Target Population for data

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.