Form 33 Checklist for Adding a New Target Population - track cha

OMB No.: 0915-0285. Expiration Date: xx/xx/xxxx

Checklist for Adding a New Target Population

Assurances:

• I certify that the following statements related to the preparation of this Change in Scope (CIS) request are true, complete and accurate:

• This CIS request is complete and responsive to all applicable criteria relating to the CIS checklist. Refer to http://www.bphc.hrsa.gov/programrequirements/scope.html for all applicable policies and guidance.

• The health center consulted with its Project Officer prior to submitting this CIS request.

• The proposed CIS implementation date is at least 60 days from the submission date to HRSA. Note: HRSA recognizes that there may be circumstances where submitting a CIS request at least 60 days in advance of the desired implementation date may not be possible; however, the goal is to minimize these occurrences through careful planning. Refer to http://www.bphc.hrsa.gov/policiesregulations/policies/pdfs/pal201410.pdf)

• The health center’s governing board approved this CIS request prior to submission to HRSA, as documented in board minutes (must be made available upon request).

• The health center has examined the potential impact of this CIS under the requirements of other programs as applicable (e.g., 340B Program, FTCA).

• The health center understands that HRSA will consider its current compliance with Health Center Program requirements and regulations (i.e., the status and number of any progressive action conditions) when making a decision on this CIS request. (See PAL: 2014-08 Health Center Program Requirements Oversight for more information on progressive action).

• I will ensure the health center complies with the following statements related to the implementation of this Change in Scope (CIS) request, if approved:

• All Health Center Program requirements (http://www.bphc.hrsa.gov/programrequirements/index.html) will apply to this CIS. Note: Compliance with Health Center Program requirements across sites and services will be assessed through all appropriate means, including site visits and application reviews.

• This CIS will be undertaken directly by or on behalf of the health center for the benefit of the current or proposed health center patient population, and the health center’s governing board will retain oversight over the provision of any services and/or sites.

• This CIS will be accomplished without additional Health Center Program Federal award funding and will not shift resources away from carrying out the current HRSA-approved scope of project.

• The impact of this CIS will be reflected in the total budget submitted with the health center’s next annual competing or non-competing or designation application.

• This CIS will be implemented and verified within 120 days of receiving the NoA or HRSA notification approving the change. Refer to http://www.bphc.hrsa.gov/policiesregulations/policies/pdfs/pal201410.pdf.

• This CIS will not diminish the patient population’s access to and quality of services currently provided by the health center.

• No additional changes in scope are necessary to implement this CIS (e.g., approval of a new site does not entail approval of any new services to be provided at the new site).

• The health center will take all applicable steps related to the requirements of other programs impacted by this change in scope request.

Change in Scope Questions:

1. OVERVIEW

Required Attachment: UDS Mapper Map & Data Table

Optional Attachment: Other Supporting Need Documentation

NOTE: The UDS Mapper Map and Data Table are required and should be used to support the explanations provided in this CIS request; upload any additional need data/documentation as necessary. HRSA will use UDS Mapper data to assess unmet need and service area overlap. If UDS Mapper Map and Data Table are not yet available, attach other relevant and comparable documentation which supports this request. UDS Mapper: http://www.udsmapper.org. For a UDS Mapper sample to support a CIS request, click here (placeholder for external resource).

1. The proposed change will add the following target population(s) to the health center’s scope of project (check all that apply):

• 330(e) General medically underserved population

• 330(g) Migratory and seasonal agricultural workers

• 330(h) Individuals experiencing homelessness

• 330(i) Residents of public housing

2. Patient Data: Provide the number and proportion of patients that your health center has served at sites within the current approved scope of project (Form 5B) from the proposed new target population(s) over the past three complete calendar years.

Year	Number of Patients from New Target Population(s) Served Annually by Health Center	New Target Population(s) Patients as a Percentage of Total health Center Patients Served Annually
		_%
		_%
		-%

3. Proposed Reallocation of Section 330 Funds: Describe how you propose that your current section 330 funding be reallocated to support services to the new target population(s).

Section 330 Funding	Current Annual (Federal) Section 330 Funding Allocation  (Based on Current 12 Month Budget Period)	Proposed Annual (Federal) Section 330 Funding Reallocation  (Based on Current 12 Month Budget Period) The sum of the proposed subprogram funding amounts must be equal to the total annual funding amount.	Projected Number of Patients to be Served in 12 Month Period following CIS Approval
330 (e ) CHC	$	$
330 (g) MHC	$	$
330 (h) HCH	$	$
330 (i) PHPC	$	$
Total Section 330 Funding/ Total Patients	$	$

2. MAINTENANCE OF APPROVED SCOPE OF PROJECT

Clearly describe in narrative format the health center’s plan for maintaining its current scope of project (i.e., sites and services) for the existing patient population(s). Specifically address how the health center is prepared to meet the primary care needs of the new target population while also assuring that resources will not be reduced for providing services to the current patient population.

Requires narrative response.

3. SERVICE AREA ANALYSIS: This section addresses how the proposed addition of this target population(s) will complement and not duplicate existing health services and resources within the service area.

Based on UDS Mapper Map and Data Table information, will the site serve all or part of a service area currently served by another health center grantee or look-alike and/or of another primary care safety net provider (rural health clinic, critical access hospital, health department, etc.)? Yes or No. Checkboxes for Yes options to allow multiple selections; No skips narrative; Any Yes response requires narrative response.

• No

• Yes – the site will serve a newly identified sub-group/underserved population (e.g., people experiencing homelessness, populations with limited English proficiency within the service area), whose health care needs are not being met.

• Yes – the site will serve an area where unmet need exceeds the capacity of the existing health center site(s) and/or other safety net providers.

• Yes – the site will serve a population where the distance and travel time to the nearest safety-net provider site, (e.g., health center grantee or look-alike, rural health clinic, critical access hospital) is a barrier for patients to access care.

• Note: UDS Mapper is the best tool for identifying the nearest Health Center Program grantee or look-alike. Distance should be measured as the distance (in miles) from the address of the proposed service site to the nearest Health Center Program grantee or look-alike service sites. Use the UDS Mapper Distance tool and/or Google Maps to determine (1) the distance in miles between sites and (2) travel time by driving or public transportation, as appropriate (e.g., if at least 30% of the patient population uses public transportation as the main source of transportation to work, provide travel time based on public transport as opposed to providing travel time by car/drive time).

• Distance in miles: _____

• Travel time in minutes: _____

Required for any Yes response: Based on this answer and attached UDS Mapper data and other needs assessment documentation that shows other health centers and service providers and their penetration rates, address any service area overlap and how the proposed site will complement existing services and programs so as to minimize the potential for unnecessary duplication and/or overlap in services, sites or programs.

Requires narrative response.

Note: Upload any relevant letters of support from all health centers serving the same service area in the next section

3. COLLABORATION WITH HEALTH CENTERS AND OTHER SAFETY NET PROVIDERS

For the purposes of this question, collaborative relationships are those that contribute to one or both of the following goals relative to the proposed target population:

(1) maximize access to required and additional services within the scope of the health center project for target population patients that will be served; and/or

(2) promote the continuity of care of target population patients by coordinating with the services and activities of other federally funded, as well as State and local, health services delivery projects and programs serving the same or a similar patient population (e.g., other health centers, rural health clinics, hospitals, health departments).

1. Describe the established and/or proposed collaborative efforts with other health centers and safety net providers (e.g., health departments, rural health clinics, hospitals) within and adjacent (e.g., neighboring ZIP codes) to the service area and how this collaboration will benefit the new target population.

Requires narrative response.

2. Attach documentation of collaboration, including any agreements (e.g., MOA, MOU, contract), relevant and specific to the proposed site which support the response to 4a. If documentation could not be obtained, describe the outreach made to these service area providers concerning this proposed target population and the result of this outreach.

Optional narrative response:

Optional attachment: Documentation of Collaboration

3. PLAN to meet newly applicable program requirements: The addition of a new target population may impact which Health Center Program Requirements apply to the health center. Address how the health center can or will demonstrate compliance with any newly applicable Health Center Program Requirements resulting from the addition of the proposed target population(s). Attach supporting documentation (e.g., existing bylaws that already demonstrate compliance, draft revised bylaws, etc.).

Resources:

• Health Center Program Governance Policy Information Notice 2014-01: http://bphc.hrsa.gov/programrequirements/policies/pin201401.html

• Form 5A: Services Provided - Service Descriptors

http://bphc.hrsa.gov/archive/about/requirements/scope/form5aservicedescriptors.pdf

Newly Applicable Proram Requirements (applicable section depends on type of population added)

New Target Population - 330(e): General Underserved Community

Newly Applicable Program Requirement - Board Composition: Document that the health center’s governing board currently meets all of the following board composition requirements. If the board does not yet meet these requirements, describe how and when they will be met:

• The health center governing board is composed of a majority of individuals whom are being served by the center and this majority as a group, represent the individuals being served by the center in terms of demographic factors such as race, ethnicity, and sex.

• The overall governing board has at least 9 but no more than 25 members, as appropriate for the complexity of the organization.

• The non-patient/consumer members of the board are representative of the community in which the center's service area is located and are selected for their expertise in community affairs, local government, finance and banking, legal affairs, trade unions, and other commercial and industrial concerns, or social service agencies within the community.

• No more than one half (50%) of the non-patient/consumer board members derives more than 10% of their annual income from the health care industry.

Plan for Demonstrating Compliance with Program Requirement: Requires narrative response

New Target Population - 330(h): Individuals Experiencing Homelessness

Newly Applicable Program Requirement - Required and Additional Services: Describe how the health center will assure that all appropriate substance abuse services for homeless populations are or will be available (either directly or via a formal written referral arrangement) among their required services.

Plan for Demonstrating Compliance with Program Requirement: Requires narrative response

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 30 minutes 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 14N-39, Rockville, Maryland, 20857.

Change Checklist

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration CHECKLIST FOR ADDING TARGET POPULATION (CHKLST016)	Grantee Name:
	Grantee Number:
	CIS Tracking Number:

Questions for Adding Target Population for Grantee

1. When do you plan to start serving the new target population noted below?

2.	BACKGROUND AND JUSTIFICATION FOR TARGET POPULATION ADDITION Provide brief background/justification for why your health center is proposing add this new target population to your scope of project by addressing ALL of the following questions.

2a.

Clearly address why and how the addition of the new target population will address unmet need and further the mission of the health center. In responding, address any or all of the following points as applicable: Is there an increased demand from this new target population in general in the service area? Is there a decrease in demand from the existing target population(s) served? Are there other environmental or demographic changes, which have resulted in fluctuations, or declines in existing target populations and present a need to redirect resources to another target population?

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Supporting Documents for Addition of New Target Population (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

2b.

Using the three most recent years of health center data, provide the number and proportion of patients from the proposed new target population that your health center has served. These data should be based on patients seen at sites within the current approved scope of project as documented on Form 5B .

Year	Number of Patients from New Target Population Served Annually by Health Center	New Target Population Patients as a Percentage of Total Health Center Patients Served Annually
20		%
20		%
20		%

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3.

MAINTENANCE OF ACCESS, LEVEL AND QUALITY OF CARE Clearly describe in narrative format, the health center’s plan for maintaining access to health center services and for maintaining the health center's total level or quality of health services provided to the current target population(s). Specifically address how the health center will assure that the addition of the new target population will not inappropriately shift resources away from providing services for the current target population.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

4.

SERVICE AREA ANALYSIS Describe how the health center has analyzed the service area, utilizing UDS Mapper and/or other similar resources, to assess the impact of adding the proposed target population on the viability of neighboring health centers. Attach your analysis documentation below. Service Area Analysis Resources Service Area Overlap Policy and Process: http://bphc.hrsa.gov/policiesregulations/policies/pin200709.html UDS Mapper: http://www.udsmapper.org HRSA Data Warehouse: http://datawarehouse.hrsa.gov

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Service Area Analysis (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

Responses should be consistent with data and narrative on demand, need and projected patients provided in Question 2.

4a.

By adding this target population, will your health center now serve all or part of the target population of another health center (section 330 grantee or look-alike) and/or of another primary care safety net provider (rural health clinics, critical access hospitals, health departments, etc.)? For the purposes of this question: Service area is defined by the service area zip codes associated with your Form 5B sites. Patient population is defined by your current UDS Patient Origin Data. Target population is defined in your most recent approved application.

Yes

No

	If Yes, list these other health centers and/or safety net providers and discuss how this change in scope will complement these existing primary care resources for the target population so as to minimize the potential for unnecessary duplication and/or overlap in services, sites, or programs. Continue to 4b only if this change in scope will result in your health center serving all or part of the target population of another health center (section 330 grantee or look-alike). Otherwise, continue to Question 5.
	Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
	If No, continue directly to Question 5.

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4b.

As the health center is proposing to serve all or part of the target population of another health center, discuss the necessity and justification of this overlap (e.g. do the health care needs of the proposed new target population exceed the capacity of the existing health center(s) site(s) in the service area?) See PIN 2007-09: Service Area Overlap Policy and Process for more information HRSA’s principles for assessing individual situations of service area overlap.

	Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)
	Once completed, continue to Question 5.

5.

COLLABORATION For the purposes of this question: Collaborative relationships are those that assist in contributing to one or both of the following goals relative to the proposed target population addition: (1) maximizing access to required and additional services within the scope of the health center project to the new target population; and/or (2) promoting continuity of care to health care services for health center patients from the new target population beyond the scope of the project. Collaboration Resources Collaboration PAL: http://bphc.hrsa.gov/policiesregulations/policies/pal201102.html UDS Mapper: http://www.udsmapper.org

5a.

Describe established collaboration and new collaborative efforts under development with existing health centers (section 330 grantee and Look-Alikes) that also serve the proposed new target population. In addition, list the names and addresses of these health centers and/or refer to the attached Service Area Analysis from Question 4 if listed there. If service area collaboration has already been discussed in Service Area Analysis Question 4a. Refer back to these responses. If a formal affiliation (e.g. MOA, MOU, contract, etc.) and/ or letter of collaboration or support from the neighboring health center(s) is available, attach these documents below. Only documents that speak to the proposed change in scope request for the target population addition should be included. ✔ If no other health centers exist within or adjacent to the service area that serves this target population state this. ✔ If documentation of collaboration or support from service area health centers that serve this target population cannot be obtained, include documentation of efforts made to obtain such documents and an explanation for why they could not be obtained.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Collaboration Documentation-Health Centers (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

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5b.

Describe established collaboration and new collaborative efforts under development with other safety net providers and programs (e.g. Migrant Head Start, Public Housing Authority, homeless shelters, rural health clinics, critical access hospitals, health departments, etc.) that also serve the proposed new target population. In addition, list the names and addresses of these other safety net providers and/or refer to the attached Service Area Analysis from Question 4 if listed there). If service area collaboration has already been discussed in Service Area Analysis Question 4a, refer back to these responses. If a formal affiliation (e.g. MOA, MOU, contract, etc.) and/or letter of collaboration or support relevant to the proposed target population addition is available, attach these documents below. Only documents that speak to the proposed change in scope request for the target population addition should be included. ✔If no other safety net providers or programs exist within or adjacent to the service area that serve this target population, state this. ✔If documentation of collaboration or support from service area safety net providers that serve this target population cannot be obtained, include documentation of efforts made to obtain such documents and an explanation for why they could not be obtained.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Collaboration Documentation-Other Safety Net Providers/Programs (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

6a.

COMPLIANCE WITH NEWLY APPLICABLE PROGRAM REQUIREMENTS Address how the health center can or will demonstrate compliance with any newly applicable Health Center Program Requirements resulting from the addition of the proposed target population. Attach supporting documentation below (e.g. existing bylaws that already demonstrate compliance, draft revised bylaws, MOAs, etc.).

New Target Population	330(e): General Underserved Community
Newly Applicable Program Requirement	Board Authority: Document that the health center’s governing board already holds monthly meetings. If it does not, document when it will begin requiring monthly meetings. Board Composition: Document that the health center’s governing board currently meets all of the following board composition requirements. If the board does not yet meet these requirements, describe how and when they will be met: The health center governing board is composed of a majority of individuals whom are being served by the center and this majority as a group, represent the individuals being served by the center in terms of demographic factors such as race, ethnicity, and sex. The overall governing board has at least 9 but no more than 25 members, as appropriate for the complexity of the organization. The non-patient/consumer members of the board are representative of the community in which the center's service area is located and are selected for their expertise in community affairs, local government, finance and banking, legal affairs, trade unions, and other commercial and industrial concerns, or social service agencies within the community. No more than one half (50%) of the non-patient/consumer board members derives more than 10% of their annual income from the health care industry.
Plan for Demonstrating Compliance with Program Requirement	Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

New Target Population	330(g): Migratory and Seasonal Agricultural Workers
Newly Applicable Program Requirement	Board Composition (for health center’s with existing waivers of the patient majority board composition requirement): Describe how the current or any new proposed alternative mechanism(s) for gathering and utilizing patient input (e.g., separate advisory boards, patient surveys, focus groups), will incorporate input from the new target population.
Plan for Demonstrating Compliance with Program Requirement	Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

New Target Population	330(h): Homeless Individuals
Newly Applicable Program Requirement	Required and Additional Services: Describe how the health center will assure that all appropriate substance abuse services are available (either directly or via a formal written referral arrangement) among their required services. Board Composition (for health center’s with existing waivers of the patient majority board composition requirement): Describe how the current or any new proposed alternative mechanism(s) for gathering and utilizing patient input (e.g., separate advisory boards, patient surveys, focus groups), will incorporate input from the new target population.
Plan for Demonstrating Compliance with Program Requirement	Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

New Target Population	330(i): Residents of Public Housing
Newly Applicable Program Requirement	Accessible Hours of Operation/Locations: Document that existing service sites are immediately accessible to the targeted public housing communities. Board Composition (for health center’s with existing waivers of the patient majority board composition requirement): Describe how the current or any new proposed alternative mechanism(s) for gathering and utilizing patient input (e.g., separate advisory boards, patient surveys, focus groups), will incorporate input from the new target population.
Plan for Demonstrating Compliance with Program Requirement	Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

Supporting Documentation - Compliance with Newly Applicable Requirements (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

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6b.

GOVERNANCE Consider and discuss any plans to address, the following general aspects of the Board Composition Governance Requirements that may be impacted by the addition of the new target population: Will the addition of the new target population significantly change the size and complexity of the overall health center organization and create the need to recruit additional board members to increase the board’s size? Will the addition of the new target population impact the need to recruit additional board members with expertise in areas not currently reflected on the board?

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

7.

SLIDING FEE DISCOUNT PROGRAM Will the health center offer its current sliding fee discount program (sliding fee discount schedule, including any nominal fees and related implementing policies and procedures) to patients from the new target population with incomes at or below 200 percent of the Federal Poverty Guidelines, and ensure that no patients will be denied access to the service due to inability to pay?

Yes

No

If No, briefly explain your response:

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

8.	Financial Impact Analysis

Download Template
Template Name	Template Description	Action
Financial Impact Analysis	Template for Financial Impact Analysis
Instructions	Instructions for Financial Impact Analysis

Attach Financial Impact Analysis Document here.

Financial Impact of Change in Scope (Maximum 6 attachments)
Select	Purpose	Document Name	Size	Uploaded By	Description
No attached document exists.

8a.

Explain how the addition of the proposed target population to scope will be accomplished and sustained without additional section 330 Health Center Program funds. Specifically (referencing the attached Financial Impact Analysis, as necessary) describe how adequate revenue will be generated to cover all expenses as well as an appropriate share of overhead costs incurred by the health center in providing services to the new target population. The Financial Impact Analysis must at a minimum show a break-even scenario or the potential for generating additional revenue. Additional revenue (program income) obtained through the addition of a new target population must be invested in activities that further the objectives of the approved health center project, consistent with and not specifically prohibited by statute or regulations.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

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8b.	Is this change in scope dependent on any special grant, foundation or other funding that is time-limited, e.g., will only be available for 1 or 2 years?

Yes

No

If Yes, how will the new target population be supported and sustained when these funds are no longer available? Describe a clear plan for sustaining services for the new target population.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

All time-limited or special one-time funds should be clearly identified as such in the Financial Impact Analysis.

9.

PROPOSED REALLOCATION OF SECTION 330 FUNDS How do you propose that your current section 330 funding be reallocated to support services to the new target population? In proposing this reallocation, please provide a breakout of the current and projected number of patients served from both the current target population and the new target population.

Section 330 Funding	Current Annual (Federal) Section 330 Funding Allocation (Based on Current 12 Month Budget Period )	Proposed Annual (Federal) Section 330 Funding Reallocation (Based on Current 12 Month Budget Period)	Current Number of Patients Served in the most recent Calendar Year	Projected Number of Patients to be Served in 12 Month Period following CIS Approval
330(g)
330(e)
330(i)
330(h)
Total Section 330 Funding/Total Patients	$	$

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10.

STAFFING Provide a clear and comprehensive description of the relevant staffing arrangements made to support the proposed new target population and to ensure staffing is/will be sufficient to meet any projected patient/visit increases. The discussion of “staffing” should include non-health center employees if the new target population will be served via contracts and/or subrecipient arrangements. In addition, describe any potential impact on the overall organization’s staffing plan (reference the Financial Impact Analysis as applicable). Specifically describe any key management staff that will supervise/oversee operations related to the new target population and who they will report to within the larger health center organizational structure (e.g. CMO, COO, etc.).

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

11.

HEALTH CENTER STATUS Discuss any major changes in the health center’s staffing, financial position, governance, and/or other operational areas, as well as any unresolved areas of non-compliance with Program Requirements (e.g. active Progressive Action conditions) in the past 12 months that might impact the health center’s ability to implement the proposed change in scope.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

12.

CREDENTIALING AND PRIVILEGING How has the health center planned for the appropriate credentialing and privileging of all provider(s) that will serve the new target population in accordance with PIN 2002-22? If there will be no change in provider staffing, state this. In responding, consider the following: It is the responsibility of the health center to ensure that all credentialing and privileging of providers has been completed BEFORE providing services to the current or new target population as part of their Federal scope of project. This includes services provided either Directly (Form 5A: Column I) OR via a (Form 5A: Column II) Formal Written Agreement (e.g. contract). For services provided via a Formal Written Referral Arrangement (Column III), the referral provider should be able to assure to the health center that all their providers are appropriately credentialed and privileged individually. The health center’s current board-approved policy must cover the required verification of credentials and establishment of privileges to perform any new activities and procedures expected of providers by the health center or be updated to do so (for services provided either Directly (Form 5A: Column I) OR via a (Form 5A: Column II) Formal Written Agreement.

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

13.

QUALITY IMPROVEMENT/ASSURANCE PLAN How will the proposed new target population be integrated into and assessed via the health center’s quality improvement/assurance and risk management plans? In responding, please address the following: Will the new target population be integrated into the current QI/QA plan? Are risk management plans in place to assure that any appropriate liability coverage areas related to providing services to the new target population will be addressed (e.g. non-medical/dental professional liability coverage, general liability coverage, automobile and collision coverage, fire coverage, theft coverage, etc.)?

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

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14.	SITES AND SERVICES Will this change in scope result in the need to add new sites, services and/or other locations to the current scope of project (Form 5A, Form 5B, Form 5C)?

Yes, but a separate CIS request(s) will be submitted to add all new sites, services and/or other locations to scope No

Additional Considerations for Adding a Target Population to Scope While the following areas are not specific factors or criteria that will impact the CIS approval process, these are key elements that health centers should have considered or actively planned to address prior to adding a new target population to scope:

A.	Medical Malpractice Coverage: Your health center must develop plans for medical malpractice coverage for any new providers that will serve the new target population (e.g., extension of FTCA coverage, private malpractice coverage). Respond to the following as applicable:

For grantees deemed under the FTCA, have your reviewed the FTCA Health Center Policy Manual or if appropriate, consulted with BPHC to assure the applicability of FTCA coverage? The FTCA Health Center Policy Manual is available at: http://www.bphc.hrsa.gov/policiesregulations/policies/pin201101.html For specific questions, contact the BPHC HelpLine at: 1-877-974-BPHC (2742) or Email: bphchelpline@hrsa.gov. Available Monday to Friday (excluding Federal holidays), from 8:30 AM – 5:30 PM (ET), with extra hours available during high volume periods.

Yes	Not Applicable, health center is not deemed or FTCA coverage does not apply.

If you selected "Not Applicable", respond to the question below.

For health centers not deemed under the FTCA or if FTCA coverage is not applicable, have you developed a plan for medical malpractice coverage?

Yes

No

Not Applicable

Briefly explain your response:

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

B.	Facility Requirements: Has your health center assured that all applicable Federal, State and local standards/accreditation requirements of the facility(ies) where the proposed new target population will be served have been fully met (including those associated with CMS FQHC certification)?

Yes	Not Applicable

Briefly explain your response:

Maximum paragraph(s) allowed approximately: 3 (3000 character(s) remaining)

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