Form 8 Health Center Agreements

OMB No.: 0915-0285. Expiration Date: 10/31/2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

FORM 8: HEALTH CENTER AGREEMENTS

FOR HRSA USE ONLY

Application Tracking Number

Grant

Number

PART I

1. Do you have, or propose to establish as part of this application, an agreement with another organization to carry out a substantial portion of the proposed scope of project?	___ Yes ___ No
If Yes, indicate the number of each agreement type in 2a and/or 2b below and complete Parts II and III. If No, skip to Part II.
2a. Contract for a substantial portion of the proposed scope of project for any of the following: core primary care providers, non-provider health center staff, Chief Medical Officer (CMO), or Chief Financial Officer (CFO).	___ (number)
2b. Memorandum of Understanding (MOU)/Agreement (MOA) for a substantial portion of the proposed scope of project via a sub-recipient/subaward arrangement.	___ (number)

PART II

1. Governance Checklist Does the health center affirm that the board exercises the authorities, legislative and regulatory mandated functions, and responsibilities listed below, without limitation or compromise due to an affiliation or agreement with another entity?	Yes	No
determines board composition	[ _ ]	[ _ ]
determines executive committee function and composition	[ _ ]	[ _ ]
selects board chairperson	[ _ ]	[ _ ]
selects board members	[ _ ]	[ _ ]
performs strategic planning	[ _ ]	[ _ ]
approves the center’s annual budget	[ _ ]	[ _ ]
directly employs, selects/dismisses, and evaluates the CEO/Executive Director	[ _ ]	[ _ ]
adopts policies and procedures for personnel and financial management	[ _ ]	[ _ ]
establishes center priorities and allocates resources	[ _ ]	[ _ ]
establishes eligibility requirements for partial payment of services	[ _ ]	[ _ ]
provides for an independent audit	[ _ ]	[ _ ]
evaluates center activities	[ _ ]	[ _ ]
adopts center's health care policies, including scope and availability of services, location, hours of operation, and quality of care audit procedures	[ _ ]	[ _ ]
establishes a conflict of interest policy	[ _ ]	[ _ ]

Examples of compromising arrangements include overriding approval or veto authority by another entity, dual majority requirements, and super-majority requirements.

A No response to any Governance Checklist item must result in a Yes response in 2 below.

2. Do you have, or propose to establish as part of this application, an agreement/arrangement (noted in Part I or otherwise) that impacts the applicant’s governing board composition, authorities, functions, or responsibilities?

___ Yes

___ No

If Yes, indicate the number of such agreements/arrangements in 3 below and complete Part III.

3. Agreement/arrangement that impacts the health center’s governing board composition, authorities, functions, or responsibilities (e.g., parent subsidiary model, bilateral board representation, outside nomination of board members, joint committees).

___ (number)

PART III

If Yes was selected for Part I.1 or Part II.2, provide Organization Agreement Details for each organization with which you have an agreement/arrangement. All agreements/arrangements must be uploaded in full. Uploaded documents will NOT count against the page limit.
Organization Agreement Details
Organization Name
EIN
Physical Location Address
Explain the history of each agreement/arrangement that impacts the health center’s governing board composition, authorities, functions, or responsibilities, (e.g., why it was entered into, how it has changed over time). If not applicable for this organization, write “n/a”.
Upload all agreements with this organization.

Note: When a health center grantee wishes to establish an agreement/arrangement in the future that will either (1) result in another organization carrying out a substantial portion of the approved scope of project or (2) impact the governing board’s composition, authorities, functions, or responsibilities, a Prior Approval request must be submitted in EHB and approved by HRSA before the agreement/arrangement can be formalized and implemented.

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.