Form 4 - Community Characteristics - Health Resources And Services Administration (Page 3 of 4) in pdf

Special Populations and

Target

Service Area

Population

Select Population

Number

Percent

Number

Percent

Characteristics

will auto-

Migratory/Seasonal Agricultural

calculate in EHB

Workers and Families

will auto-

People Experiencing

calculate in EHB

Homelessness

will auto-

Residents of Public Housing

calculate in EHB

will auto-

School Age Children

calculate in EHB

will auto-

Veterans

calculate in EHB

will auto-

Lesbian, Gay, Bisexual, and

calculate in EHB

Transgender

HIV/AIDS-Infected Persons

Individuals Best Served in a

will auto-

Language Other Than English

calculate in EHB

Other

will auto-

Please Specify (maximum 200

calculate in EHB

Characters): ______________

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 1 hour 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 1014-N39, Rockville, Maryland, 20857.

Instructions for Form 4: Community Characteristics

Report current service area and target population data. If you compile data from multiple data sources,

the total numbers may vary across sources. If this is the case, make adjustments as needed to ensure

that the total numbers for the first four sections of this form match. Adjustments must be explained in the

NEED section of the Project

Narrative.

Service area data must be specific to the proposed project and include the total number of individuals for

each characteristic (percentages will automatically calculate in HRSA EHB). If information for the service

area is not available, extrapolate data from the U.S. Census Bureau, local planning agencies, health

departments, and other local, state, and national data sources. Estimates are acceptable.

Target population data are most often a subset of service area data. Report the number of individuals for

each characteristic (percentages will automatically calculate in HRSA EHB). Estimates are acceptable.

Patient data should not be used to report target population data since patients are typically a

subset of all individuals targeted for service.

Form 4 - Community Characteristics - Health Resources And Services Administration Page 3

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