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Site Development Manual: Chapter 5
Exhibit 5-5: NEED FOR ASSISTANCE WORKSHEET FOR NEW ACCESS POINTS - FISCAL YEAR 2004*
MUST BE COMPLETED AND INCLUDED WITH THE GRANT APPLICATION
All responses in this section must be given in the format requested (i.e., if a percentage is requested, the response must be a percentage; if a rate is requested, the response must be a rate). If the response is not provided in the requested format, the applicant will receive the minimum points allowed for that question.
Documentation of the source of the data is required. If there is no source documented, the applicant will only receive the minimum points allowed for that question.
Applications that score 70 or higher on the need for assistance component of the application will have the merits of the application evaluated by an Independent Review Committee.
See Attachment C, on the next page, for scoring of the Need for Assistance Worksheet.
| Respond to five (5) of the Barriers and Access to Care questions in Attachment C, Section 1. Please write in the Question # in the first column, the question subject information in the second column, the applicant response in the third column and the source for the response in the fourth column. |
| Quest. # |
Question Subject information (e.g., "Geographic barriers") |
Response |
Identify Source and Date |
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| Respond to ten (10) of the Health Disparities listed in Attachment C. Please write in the Item # from Attachment C in the first column, the corresponding Health Disparity Factor in the second column, the data (rate/percent/etc.) in the target population in the third column, data (rate/percent/etc.) for comparison from National, State, County or other established reporting area in the fourth column, the source and date for the data for the target population in the fifth column and the source and date for the data for the comparison data in the final column. |
| Item # |
Health Disparity Factor |
Target
Population data |
Comparison
data |
Source and date for
target population data |
Source and date for
comparison data |
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*Source: Bureau of Primary Health Care Program Information Notice (PIN 2004-02).
Attachment C*
Eligible applicants will be evaluated in accordance with the following criteria (total 100 points):
1. BARRIERS AND ACCESS TO CARE: each applicant must respond to FIVE of the following: (maximum 70 points)
(a) Geographic barriers based on average travel time/distance by the means most commonly used by the target population (e.g., car, public transportation, walking, etc.) from home/shelter/ camp to the nearest source of primary care that is accessible to the target population (e.g., a physician willing to accept new Medicaid patients and/or has a published sliding fee schedule for people below 200 percent of poverty).
| 0 - 20 minutes |
0 points |
| 21 - 29 minutes |
6 points |
| 30 - 44 minutes |
8 points |
| 45 - 59 minutes |
10 points |
| 60 - 74 minutes |
12 points |
| 75 + minutes |
14 points |
or
| 0 - 10 miles |
0 points |
| 11 - 19 miles |
6 points |
| 20 - 29 miles |
8 points |
| 30 - 49 miles |
10 points |
| 50 - 59 miles |
12 points |
| 60 + miles |
14 points |
(b) Length of waiting time for public housing and Section 8 certificates in the proposed service area:
| Less than 90 days |
0 points |
| 3 - 5 months |
6 points |
| 6 - 12 months |
8 points |
| 13 - 18 months |
10 points |
| 19 - 24 months |
12 points |
| Greater than 25 months |
14 points |
(c) Percentage of population 5 years or older who speak a language other than English at home:
| <1 % |
0 points |
| 1 - 2 % |
6 points |
| 3 - 4 % |
8 points |
| 5 - 7 % |
10 points |
| 8 - 12 % |
12 points |
| 13 + % |
14 points |
(d) Shortage of primary care physicians necessary to meet the needs of the target population = Designation of the service area as a Federal Health Professional Shortage Area (HPSA):
| NO |
0 points |
| YES |
14 points |
(e) Percentage of Individuals Below 200 percent of the Federal Poverty Index in the Target Population
| 0 - 9% |
0 points |
| 10 - 19% |
6 points |
| 20 - 29% |
8 points |
| 30 - 39% |
10 points |
| 40 - 49% |
12 points |
| 50+ % |
14 points |
(f) Life Expectancy Rate (based on life expectancy at birth in years):
| 82+ years |
0 points |
| 77 - 81 years |
8 points |
| 73 - 76 years |
10 points |
| 68 - 72 years |
12 points |
| 0 - 67 years |
14 points |
(g) Percentage of Uninsured Individuals in the Target Population [If information is unavailable, use number of individuals below 200 percent of poverty minus the number of Medicaid beneficiaries]
| 0 - 9% |
0 points |
| 10 - 14% |
8 points |
| 15 - 24% |
10 points |
| 25 - 34% |
12 points |
| 35+ % |
14 points |
(h) Unemployment rate in the target population
| 0 - 1 % |
0 points |
| 2 - 3.5 % |
6 points |
| 3.6 - 5.0 % |
8 points |
| 5.1 - 6.5 % |
10 points |
| 6.6 - 8.0 % |
12 points |
| 8.1+ % |
14 points |
2. HEALTH DISPARITY FACTORS: Each applicant must respond to ten (10) of the following items. Responses must be based on the rate/percentage/etc., in the proposed TARGET POPULATION. If information is not available for the target population, service area data may be substituted. If the application proposes to serve a special population group, responses in this section should demonstrate the unique Health Disparities of the special population. (3 points each - maximum 30 points)
2a. Cancer rate (age adjusted death rate for all cancers per 100,000 people)
2b. Low birth weight rate (per 1,000 live births)
2c. Infant mortality rate (per 1,000 live births)
2d. Rate of exposure (i.e., hypothermia, heat stroke, etc.)
2e. Asthma rate
2f. Diabetes rate
2g. Nutrition rate (e.g., hunger, malnutrition, etc.)
2h. Coronary heart disease rate (age adjusted death rate for all cancers per 100,000 people)
2i. Rate of occupational (e.g., pesticide) and environmental hazard exposures
2j. Skin disorders rate (e.g., acne, eczema, ring worm, etc.)
2k. Dental disease rate (e.g., caries, lack of teeth, periodontal disease)
2l. Teen pregnancy rate
2m. Late entry into prenatal care
2n. Obesity rate
2o. Depression rate
2p. Suicide rate
2q. Hypertension rate
2r. HIV/AIDS/STDs rate
2s. Unintentional injury rate
2t. Percent of elderly
2u. Substance abuse rate
2v. ADD/ADHD rate
2w. Rate of respiratory infection
2x. Immunization rate
2y. Rate of school absenteeism
2z. Percent of minority populations
2aa. Rate of serious mental illness (e.g., schizophrenia, bi-polar, etc.)
2bb. Other (must be health related): ONE RESPONSE ONLY
*Source: Bureau of Primary Health Care Program Information Notice (PIN 2004-02).
