22E Form 5C - edits

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration Form 5C: OTHER ACTIVITIES/LOCATIONS		FOR HRSA USE ONLY
		Grant Number	Application Tracking Number
Activity/Location Information
Type of Activity (select one)	[_] Immunizations [_] Hospital Admitting [_] Medical Rounds [_] Home Visits [_] Health Fairs [_] Non-Clinical Outreach [_] Portable Clinical Care [_] Health Education [_] Other – Please Specify:
Frequency of Activity (max 600 characters)
Description of Activity (max 600 characters)
Type of Location(s) where Activity is Conducted

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. . paperwork@hrsa.gov HYPERLINK "https://sharepoint.hrsa.gov/sites/bphc/oppd/ED1/OMB%20Forms%20Approval%202020/paperwork@hrsa.gov" 42 U.S.C. 254b HYPERLINK "http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section254b&num=0&edition=prelim"