Name
*
First Name
Last Name
Title
*
Organization
*
Email
*
Phone
*
(###)
###
####
What year did your health center become a FQHC Look-Alike?
*
Annual cost of malpractice insurance for your organization:
*
In the past, have you applied for a New Access Point (NAP) grant to become a FQHC grantee?
*
Yes
No
If Yes, what did you score for Unmet Need (out of 20 points)?
If Yes, what did you score for the entire application (out of 100 points)?
What issues/concerns would you like us to relay to HRSA regarding the NAP application process for Look-Alikes?
*
Did you apply for and receive the FY2020 Health Center Program Look-Alikes: Expanding Capacity for Coronavirus Testing (LAL-ECT) grant?
*
Yes
No
If Yes, how much in LAL-ECT funding were you awarded?
If Yes, what percentage of the LAL-ECT grant have you drawn down to date?
If Yes, what did you use LAL-ECT funds for?
If No, why didn't / couldn't you apply for LAL-ECT funding?
If No, what would your LAL-ECT award have been (use our STIMULUS CALUCLATOR)?
If No, what would you have used the LAL-ECT funds for?
Did you apply for and receive the FY2021 American Rescue Plan: Funding for Look-Alikes (ARP-LAL) grant?
*
Yes
No
If Yes, how much in ARP-LAL funding were you awarded?
If Yes, what percentage of the ARP-LAL grant have you drawn down to date?
If Yes, what did you use the ARP-LAL funds for?
If No, why didn't / couldn't you apply for ARP-LAL funding?
If No, what would your ARP-LAL award have been (use our STIMULUS CALCULATOR)?
If No, what would you have used the ARP-LAL funds for?
Through the pandemic, did your health center shut down any clinics?
*
Yes
No
Through the pandemic, did your health center cut back hours of operation at any clinics?
*
Yes
No
Through the pandemic, did your health center lay off or furlough any employees?
*
Yes
No
To date, how many patients has your health center tested for COVID-19?
*
To date how many patients has your health center vaccinated for COVID-19?
*
Is your state Medicaid program reimbursing you for video encounters?
*
Yes
No
Is your state Medicaid program reimbursing you for telephone encounters?
*
Yes
No
Do you currently maintain capability to advertise yourself as a public testing/vaccination site, to non-patients?
*
Yes
No
Do you need additional stimulus funding for repairs, alterations, renovations, construction activities to improve space and capacity at your health centers?
*
Yes
No
Do you need additional stimulus funding for telehealth equipment?
*
Yes
No
Do you need additional stimulus funding for clinical equipment?
*
Yes
No
Do you need additional stimulus funding for COVID-19 testing and vaccination supplies (including PPE)?
*
Yes
No
Do you need additional stimulus funding for personnel (sustain or expand)?
*
Yes
No
