Form 1 Verification Checklist

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration NAP VERIFICATION CHECKLIST	FOR HRSA USE ONLY
	Application Tracking Number	Grant Number

NAP Verification Checklist

1.	Can the proposed NAP project be implemented, as described in the application, within 120 days of award if funds become available during fiscal year 2012?

[_] Yes   [_] No  If 'No', please provide a summary of any changes required to support implementation of the NAP project.  Comments:

2.	Have there been any significant changes (e.g., key management staff, operational status, organizational structure, proposed sites), that would impact the organization’s ability to fulfill the project as originally proposed in the NAP application?

[_] Yes   [_] No

If 'Yes', please provide a summary of any significant changes.  

Comments:

3.	Is it necessary to modify (remove or replace) any of the proposed NAP sites as described in the Form 5B section of the NAP application to support implementation of the NAP project?*

[_] Yes   [_] No 

If 'Yes', explain how the project will be carried out with the revised site(s). 

Comments:

4.	Did the application include any one-time funding for any sites that have been modified (removed or replaced)? Please note, NAP applicants could have requested one-time funding in Year 1 for alterations and renovations, including the installation of equipment.

[_] Yes   [_] No  

Comments:

Acknowledgement

[_]

I acknowledge that the provision of the requested information does not commit HRSA to award Health Center Program funding for the proposed NAP project detailed in my organization’s NAP application. I certify that the information provided within the checklist is current and accurate.

* If you select ‘Yes’ as the response for question 3, you must provide information in FORM 5B: SITES and OTHER REQUIREMENTS FOR SITES forms of this application.