Scope of Project Site and Service Change Request

Form to request board and HRSA review when adding or removing a site or changing services within the scope of project.

Request Overview

• Request title
• Type of request
• Submission date
• Requested effective date
  Enter the date you want the change to take effect. The effective date may be adjusted during review.

Affected Site Details

• Site name
• Site address
  Include street address, city, state, and ZIP code.
• Site type
• Current site status

Service Change Details

• Current services at this site
• Proposed services
• Summary of service change
• Impact on scope of project

Business Justification and Operational Impact

• Business justification
• Impact on patient or client access
• Staffing impact
• Budget or funding impact

Supporting Documentation

• Supporting documents
  Upload board memo, site plan, service matrix, maps, lease documents, or other supporting materials.
• Document summary
• PII minimization attestation

Review, Consent, and Submission

• Board review required
• HRSA review required
• Submitter name
• Submitter role
• Acknowledgement