15_Updated Form 1C (Revised 5.19.25)

Form 1C: Documents on File

OMB No: 0915-0285. Expiration Date: 4/30/2026

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration FORM 1C: DOCUMENTS ON FILE	FOR HRSA USE ONLY
	Grant Number	Application Tracking Number
Note: Date of Last Review/Revision must use the date format of MM/DD/YYYY. This listing does not include all policy/procedure documents required to be maintained on file. Records demonstrating the implementation of required policies and procedures must also be available for review.
Management and Finance	Date of Last Review/Revision (MM/DD/YYYY)	Not Applicable (N/A)
Personnel policies, including selection and dismissal procedures, salary and benefit scales, employee grievance procedures, and equal opportunity practices.
Policies/procedures consistent with E.O. 14273 and terms of awards to make insulin and injectable epinephrine available at or below the discounted price paid by the health center awardee or sub-awardee under the 340B Drug Pricing Program (plus a minimal administration fee) to individuals with low incomes who: (a) have a high cost-sharing requirement for either insulin or injectable epinephrine; (b) have a high unmet deductible; or (c) have no health care insurance. For this purpose, “a low-income individual” means an individual living in a household with an income level at or below 200 percent of the Federal Poverty Guidelines.
Procurement procedures.
Standards of Conduct/Conflict of Interest policies/procedures.
Financial Management/Accounting and Internal Control policies and/or procedures to ensure awarded Health Center Program federal funds are not expended for restricted activities.
Financial Management/Accounting and Internal Control policies/procedures related to restrictions on the use of federal funds for the purchase of sterile needles or syringes for the hypodermic injection of any illegal drug.1 (Only applicable if your organization provides syringe exchange services or is otherwise engaged in syringe service programs; otherwise, indicate as N/A.)
Financial Management/Accounting and Internal Control policies/procedures related to restrictions on the use of federal funds to provide abortion services, except in cases of rape or incest or where there is a threat to the life of the mother.1 (Only applicable if your organization provides abortion services; otherwise, indicate as N/A.)
Billing and Collections policies/procedures, including those regarding waivers or fee reductions and refusal to pay.
Services	Date of Last Review/Revision (MM/DD/YYYY)
Credentialing/Privileging operating procedures.
Coverage for Medical Emergencies During and After Hours operating procedures.
Continuity of Care/Hospital Admitting operating procedures.
Sliding Fee Discount Program policies, operating procedures, and sliding fee schedule.
Quality Improvement/Assurance Program policies and operating procedures that address clinical services and management, patient safety, and confidentiality of patient records.
Governance	Date of Last Review/Revision (MM/DD/YYYY)	Not Applicable (N/A)
Governing Board Bylaws.
Co-Applicant Agreement (Only applicable to public entity health centers; otherwise, indicate as N/A.)
Evidence of Nonprofit or Public Agency Status

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. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring.  The OMB control number for this information collection is 0915-0285, and it is valid until 4/30/2026. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). 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 the HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857, or paperwork@hrsa.gov.

1 Grants Policy Bulletin: Legislative Mandates in Grants Management.