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Organization Information
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1.
Organization Information
(Required.)
Health Center/PCA Name
Address
City/Town
State
Zip Code
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2.
Type of HRSA Funding
(Required.)
Community Health Center: 330(e)
Health Care for the Homeless Program: 330(h)
Migrant Health Center: 330(g)
Migrant Health Voucher Program: 330(g)
Public Housing Primary Care Health Center: 330(e)
Primary Care Association
Other approved organization
Other (please specify)
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3.
Catalogue of Federal Domestic Assistance (CFDA) Number (Please input "n/a" if you do not get HRSA funding.)
(Required.)
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4.
Organization Size/Scope:
(Required.)
How many patients/member organizations did you serve in your last project year?
How many health center sites (if applicable)?
How many employees (total FTEs)?
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5.
Primary Special Populations Served (Check up to four)
(Required.)
Migratory and seasonal agricultural workers
People experiencing homelessness
Residents of public housing
School-aged children
Aging populations
Asian Americans, Native Hawaiians, and other Pacific Islanders
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations
Immigrant populations
Refugees and/or asylees
Native Americans
Veterans
Other (Please list other Primary Special Populations Served)
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6.
Do you provide outreach services to your community members?
(Required.)
Yes
No