Form 0285-Project Cover 0285-Project Cover Capital Improvement_Investment Project Cover

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

PROJECT COVER

FOR HRSA USE ONLY

Grantee Name

Grant Number

Application Tracking #

Project #

Project Type

Project Title

1. Site Information

Current Square Footage

Cost per square foot

2. Project Management

1. Explain the administrative structure and oversight for the project, including the role and responsibilities of the health center's key management staff and governing board regarding the proposed FIP project.

2. Indicate the qualifications of the individual (the Project Manager) who will be responsible for managing the project and the individuals (Project Team) who will be implementing the project.

3. Describe how the Project Team has the expertise and experience necessary to successfully manage the project within the timeline outlined and achieve the goals and objectives established for this project.

4. If you are at an early stage in the development of your project, indicate how you intend to build your team to manage the project.

5. Describe the ongoing institutional (e.g., governing board, management) commitment to the proposed improvement or enhancements.

6. Maintain documentation that an alternatives analysis was conducted; the documentation should show at least three alternatives were considered and the rationale for selection of the proposed project.

7. Maintain documentation on the organization's acquisition strategy; if the strategy does not include competition, provide a rationale.

(Maximum 4000 Characters)

3. Contact Information

3a. Identify the individual at the health center who will be responsible for managing this project.

Project Manager
First Name			Last Name			Middle Initial
Phone #			Email
Street Address Line 1
Street Address Line 2
City			Urbanization (Used only for Puerto Rico)
State			Zip Code

3b. Identify the individuals who comprise the project team at the health center who will be responsible for managing this project. (Note: Please provide complete name and title of the team member) (Maximum 2000 Characters)

4. Need

a. Clearly identify and describe the deficiencies or the needs to be addressed with this project (e.g., fire/life safety issues, overcrowding, insufficient space, outdated/ineffective equipment, inefficient design for patient flow needs, accommodation of new or enhanced services).

b. Describe the extent to which the existing facility is inadequate to provide effective, efficient, quality care, and optimal patient outcomes for your target population.

c. Identify and discuss the target service area.

d. Identify the target population and describe the need for the proposed primary care services (e.g., demographic data, health status, barriers to care issues). State concisely the importance of this project to the organization's mission and the population it serves.

(Maximum 4000 Characters)

5. Implementation and Monitoring:

1. Describe proposed improvements in relation to the existing situation (e.g., current versus proposed number of exam rooms, square footage improved/added, access redesign and related patient flow improvements, enhanced services resulting from new equipment purchased).

2. Explain how the proposed improvements will expand or improve your organization's effectiveness, efficiency, quality of care, and patient outcomes.

3. Identify any additional sources of funding that have been secured or committed (provide the source of those funds, amount, and date committed/secured).

4. Identify the resources available to cover start-up costs (such as staff recruitment and training), operating costs, and any debt obligations.

5. Provide key qualifications and relevant experience of contractors that the applicant may contract with to facilitate the implementation of the project.

6. Explain how the organization will deal with any unexpected difficulties and/or challenges that may arise.

7. Describe the methodology that will be used to track progress with developing the facility and (ii) bringing about the service delivery impacts you anticipate.

8. Explain the risk management plan; include identification of barriers and strategies to resolve issues. Identify and list potential challenges and mitigation strategies. Quantify the probability of occurrence and the level of impact (high, medium, low).

9. Report on Earned Value Management, if possible.

(Maximum 4000 Characters)

6. Timeline

Project Completion Date (MM/YYYY)

Indicate the timeframe for demonstrating progress with this FIP project by identifying the start and end dates for each of the following critical milestones: planning, project development, procurement, implementation, and project completion. Please describe the current status of the project including any steps that may have been accomplished to date and identify the person or entity accountable for each milestone. Applicants must keep in mind that the project/budget period for FIP awards is 2 years (24 months). (Maximum 1000 Characters)