Form 9 Need for Assistance Worksheet

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

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 Note: Provide information for 3 out of the 4 Core Barriers listed below.

Population to One FTE Primary Care Physician Ratio
Data Response			____:1 (Ratio)			Year to which Data Apply
Data Source
Methodology Utilized/Data Source/ Description/Other
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or 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
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data
Percent of Population Uninsured
Data Response	_____ (%)			Year to which Data Apply
Data Source
Data Source/DescriptionMethodology Utilized/Data Source Description/Other
Methodology Utilized/Extrapolation method
Identify Geographic Service Area or Target Population for Data

Distance (miles) OR Travel Time (minutes) to Nearest Primary Care Provider Accepting New Medicaid and/or Uninsured Patients
Data Response	____ (Miles or Minutes)	Year to which Data Apply
Data Source
Data Source/Description
Methodology Utilized/Extrapolation methodData Source Description/Other
Identify Geographic Service Area or Target Population for Data

SECTION II: CORE HEALTH INDICATORS Note: Provide information for all six health indicator categories listed below. You are required to select one Core Health Indicator for each category and provide complete information for the selected indicator.

Diabetes
Core Health Indicator
National/Severe Benchmark		Pre-populated
Data Response				Year to which Data Apply
Data Source/Description
Methodology Utilized/Extrapolation methodData Source Description/Other
Identify Geographic Service Area or Target Population for Data
Cardiovascular Disease
Core Health Indicator
National/Severe Benchmark	Pre-populated
Data Response			Year to which Data Apply
Data Source/DescriptionData Source
Methodology Utilized/Extrapolation methodMethodology Utilized/Data Source Description/Other
Identify Geographic Service Area or Target Population for Data

Cancer
Core Health Indicator
National/Severe Benchmark	Pre-populated
Data Response			Year or date to which Data Apply
Data Source/DescriptionData Source
Methodology Utilized/Extrapolation methodMethodology Utilized/Data Source Description/Other
Identify Geographic Service Area or Target Population for Data
Prenatal and Perinatal Health
Core Health Indicator
National/Severe Benchmark		Pre-populated
Data Response				Year or date to which Data Apply
Data Source/DescriptionData Source
Methodology Utilized/Extrapolation methodMethodology Utilized/Data Source Description/Other
Identify Geographic Service Area or Target Population for Data
Child Health
Core Health Indicator
National/Severe Benchmark		Pre-populated
Data Response					Year or date to which Data Apply
Data Source/DescriptionData Source
Methodology Utilized/Extrapolation methodMethodology Utilized/Data Source Description/Other
Identify Geographic Service Area or Target Population for Data

Behavioral and Oral Health
Core Health Indicator
National/Severe Benchmark	Pre-populated
Data Response		Year or date to which Data Apply
Data Source/DescriptionData Source
Methodology Utilized/Extrapolation methodMethodology Utilized/Data Source Description/Other
Identify Geographic Service Area or Target Population for Data

SECTION III: OTHER HEALTH AND ACCESS INDICATORS Note: Provide information for 2 out of 13 of the Other Health and Access Indicators

Indicator #1
Other Health and Access IndicatorHealth Indicator
National Benchmark	Pre-populated
Data Response		Year to which Data Apply
Data Source/DescriptionData Source
Methodology Utilized/Extrapolation methodMethodology Utilized/Data Source Description/Other
Identify Geographic Service Area or Target Population for Data
Indicator #2
Other Health and Access IndicatorHealth Indicator
National Benchmark	Pre-populated
Data Response		Year to which Data Apply
Data Source/DescriptionData Source
Methodology Utilized/Extrapolation methodMethodology Utilized/Data Source Description/Other
Identify Geographic Service Area or 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 4.51 hours 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 14N0-393, Rockville, Maryland, 20857.