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					        FORM 9 – Part B: NEED FOR ASSISTANCE WORKSHEET – FY 2007
       MUST BE COMPLETED AND INCLUDED WITH THE GRANT APPLICATION
          OMB No.: 0915-0285. Expiration Date: 06/30/2007


       Please see instructions for completing and scoring the NFA Worksheet in Form 9 – Part A (page 3). Type or print all responses clearly.

        SECTION 1: CORE BARRIERS (Maximum 45 points)
       Respond to all three (3) of the CORE BARRIERS in Form 9 – Part A. Please write in the Barrier response in column (a), the data source for the response in column (b), date
       data in column (c), state whether the data provided is based on a geographic service area or a specific target population (e.g. migrant or homeless persons) in column (d) and, if us
       alternate data source, provide a brief explanation as to why that source is more appropriate in column (g). As a reminder, applicants MUST use the data source provided in the NF
       Data Resource Guide to respond to Barrier (b): Percent of Population at or Below 200 percent of poverty.
                                                                                                      Year or date to which data   Identify Target Population Explanation for Use of

                                                                                                                                                              Alternate Data Source
       Question                              Barrier                     Response Data Source                   apply                     for data
          (a)                                  (b)                          (c)             (d)                  (e)                         (f)                        (g)
           a.           Population to Primary Care Physician Ratio        3070:1           OPC                  2006                  Any Co. District 2
                        Percent of Population at or Below 200 percent of
              b.        poverty                                            53%          U.S. Census             2006                  Any Co. District 2         Not Applicable
              c.        Percent of Population Uninsured                  18%           U.S. Census              2006                  Any Co. District 2
        SECTION 2: OTHER BARRIERS (Maximum 30 points)
       Respond to two (2) out of five (5) of the OTHER BARRIERS in Form 9 – Part A. Please write in the Other Barrier letter for the selected barrier in column (a), the question
       subject information in column (b), the Other Barrier response in column (c), the data source for the response in column (d), date of the data in column (e), state whether the data
       provided is based on a geographic service area or a specific target population (e.g. migrant or homeless persons) in column (e), and if using an alternate data source, provide a
       brief explanation as to why that source is more appropriate in column (g). As a reminder, applicants MUST use the data source provided in the NFA Data Resource Guide to
       respond to Barrier (g): 12-Month Average Unemployment Rate.
                                                                                                      Year or date to which data

       Question         List Barrier (e.g., “Travel Time”)            Response Data Source                    apply                       Identify Target Population for data
          (a)                                   (b)                      (c)             (d)                   (e)                                        (f)
         (d)                                Travel Time                 37.81        Mapquest               15-May-07                             Any Co. District 2
         (f )                       Age Adjusted Death Rate             1042    Ms. St. Dept Health     2004                                      Any Co. District 2



   FORM 9 – B: B: NEED FOR ASSISTANCE WORKSHEET – FY 2007, Page
FORM 9 – PartPartNEED FOR ASSISTANCE WORKSHEET – FY 2007, Page 1 2
OMB No.: 0915-0285. Expiration Date: 06/30/2007
 OMB No.: 0915-0285. Expiration Date: 06/30/2007



SECTION 3: CORE DISPARITIES (Maximum 15 points)
Respond to one (1) Disparity indicator from within each of the five (5) Disparity categories numbered 1 through 5 listed in Form 9 – Part A. Please write in the Disparity categ
indicator # from Form 9 – Part A in column (a), list the specific Disparity Factor Indicator in column (b), the disparity response in column (c), the data source for the response in column
date of the data in column (e), state whether the data provided is based on a geographic service area or a specific target population (e.g. migrant or homeless persons) in column (f), and,
using an alternate data source, provide a brief explanation as to why that source is more appropriate in column (g). If providing an “other” disparity category factor, the applicant must d
the factor (which must be related and specific to that disparity category) and present the national benchmark as well as the response for that Disparity factor.
                 Indicator #                           Disparity Factor Indicator (e.g., “Diabetes          Response               Data Source (Provide        Year or date to    Identify Target Population for data


                (e.g. “1 (e)”).                               Prevalence for ages 20-39”)                                       benchmark if using “Other”)    which data apply
                      (a)                                                 (b)                                  (c)                          (d)                (e)                                (f)
Diabetes/Obesity: 1.( f )                            Adult Obesity Prevalence                                            32% Ms. State Dept. Health                       2005           Any Co. District 2
CV Disease: 2.( d )                                  Morbidy from Disease of Hearth                                     510.6 Ms. State Dept. Health                       2005          Any Co. District 2
Asthma, Resp. Disease: 3.( h )                       Emphysema and other Chronic Lower                                  105.9 Ms. State Dept. Health                       2005          Any Co. District 2
Pre & Perinatal Health 4.( c )                       Respiratory Diseases (15-19)
                                                     Births to Teen Mothers                                             16.9% Ms. State Dept Health, 2005                  2005          Any Co. District 2
Mental Hlth,/ Sub. Abuse . ( b )                     Suide Rate                                                 18.59/100,000 Ms. State Dept Health, 2005                  2005           Any Co. District 2
SECTION 4: OTHER DISPARITIES (Maximum 10 points)
Respond to five (5) out of ten (10) of the Disparity factors numbered 6 through 15 listed in Form 9 – Part A, Section 2 Disparities: Part B. Please write in the disparity indicator
from Form 9 – Part A in the first column, list the specific Disparity Factor Indicator in the second column, the disparity response in the third column, the data source for the response in t
fourth column, date of the data in the fifth column, state whether the data provided is based on a geographic service area or a specific target population (e.g. migrant or homeless persons
the sixth column, and if using an alternate data source, provide a brief explanation as to why that source is more appropriate in the seventh column. If providing a disparity factor under
“Other,” the applicant must define the factor (which must be a disparity related to the population or area to be served), present the national benchmark as well as the response for that fac
Indicator # (e.g.                   Disparity Factor Indicator (e.g., “HIV               Response    Data Source (Provide benchmark if using   Year or date to which data apply   Identify Target Population for data
“7”)                                               Seroprevalence”)                                                  “Other”)
              (a)                                        (b)                                 (c)                       (d)                                    (e)                                 (f)
        (10)                 No Pap test in past 3 years; women 18+                          16                        CDC                                  2006                        Any Co. District 2
        (11)              No Mammogram in past 3 years; Women                               32.2                       CDC                                  2006                        Any Co. District 2
                                            40+
        (12)              No FOBT within the Past 2 years; adults                           78.2                       CDC                                  2006                        Any Co. District 2
                                            50+
        (14)             Adults diagnosed with Diabetes                                     10.9                       CDC                                  2005                        Any Co. District 2

        (15)              Adults aged 65+who have not had a flu shot                        34.6                       CDC                                  2006                        Any Co. District 2
                                       within past year
No FOBT within the past 2 years; adults 50+
– No Mammogram in past 3 years; women 40+
No Pap test in past 3 years; women 18+
esponse in column (b), date of the
 ns) in column (d) and, if using an
 a source provided in the NFA


                Explanation for Use
                  of Alternate Data
                       Source
                         (g)
                    NFA Guide         11   15

                   Not Applicable     13   15
                    NFA Guide          9   15
                                      33   45
 n column (a), the question
(e), state whether the data
e data source, provide a
Data Resource Guide to

                Explanation for Use
                 of Alternate Data
                      Source
                     (g)
                Most Current          15   15
                Most Current          11   15
                                      26   30
 write in the Disparity category
e for the response in column (d),
persons) in column (f), and, if
 factor, the applicant must define

                 Explanation for Use of


                 Alternate Data Source
                           (g)
                Current                    3    3
                Current                    3    3
                Current                    2    3
                Current                    3    3
                Current                    3    3
                                          14   15
 ite in the disparity indicator #
 source for the response in the
migrant or homeless persons) in
ing a disparity factor under
l as the response for that factor.
                 Explanation for Use of
                 Alternate Data Source
                           (g)
                     NFA Guide             2    2
                     NFA Guide
                                           2    2
                     NFA Guide
                                           2    2
                     NFA Guide
                                           2    2
                     NFA Guide
                                           2    2
10 10
83 100

				
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