Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Annual Emergency Preparedness Report Modified 1600 1600 0 Form 10 Annual Emergency Preparedness Report
Checklist for Adding New Service Modified 700 1400 0 Form 1 Checklist for adding new service
Checklist for Adding a New Target Population New 50 50 0 Form 1 checklist for adding a new target population
Checklist for Adding a new Service Delivery Site Modified 700 1400 0 Form 1 Checklist for Adding a New Service Delivery Site
Checklist for Deleting Existing Service Modified 700 1400 0 Form 1 Checklist for deleting existing service
Checklist for Deleting Existing Service Delivery Site Modified 700 1400 0 Form 1 Checklist for Deleting Existing Service Delivery Site
Checklist for Replacing Existing Service Delivery Site Modified 700 1400 0 Form 1 Checklist for replacing existing service delivery site
Clinical Performance Measures Modified 1600 3200 0 Form 1 Clinical Performance Measures
Community Characteristics Modified 650 650 0 Form 4 Community Characteristics
Current Board Member Characteristics Modified 1600 1600 0 Form 6a Current Board Member Characteristics
Documents on File Modified 650 650 0 Form 1C Documents on File
EHR Readiness Checklist New 50 25 0 Form 1 EHR Readiness Checklist
Equipment List Modified 400 400 0 Form 1 Equipment List
Financial Performance Measures Modified 1600 1600 0 Form 1 Financial Performance Measures
Funding Request Summary Modified 400 400 0 Form 1B Funding Request Summary
Funding Sources New 400 200 0 Form 1 Funding Sources
General Information Worksheet Modified 1700 3400 0 Form 1 General Information Worksheet
Health Center Agreements Modified 250 250 0 Form 8 Health Center Agreements
Implementation Plan New 400 1200 0 Form 1 Implementation Plan
Income Analysis Modified 1600 4800 0 Form 3 Income Analysis
Increased Demand for Services New 1200 1200 0 Form 1 Increased demand for services
Look Alike Budget New 100 100 0 Form 1 Look Alike Budget
Need for Assitance Worksheet Modified 650 3250 0 Form 9 Need for Assistance Worksheet
O&E Progress Report New 1200 1200 0 Form 1 O&E Progress Report
O&E Supplemental New 1200 1200 0 Form 1 O&E Supplemental
Organization Contacts Modified 1600 800 0 Form 12 Organization Contacts
Other Activities/Locations Modified 1600 800 0 Form 5c other activities/locations
Other Requirements for Sites Modified 400 200 0 Form 1 Other Requirements for Sites
Project Cover Page Modified 400 400 0 Form 1 Project Cover Page
Project Qualification Criteria New 400 400 0 Form 1 Project Qualification Criteria
Project Work Plan New 100 400 0 Form 1 Project Work Plan
Proposal Cover Page Modified 400 400 0 Form 1 Proposal Cover Page
Request for Waiver of Governance Requirements Modified 150 150 0 Form 6b Request for waiver of governance requirements
Service Sites Modified 1600 1600 0 Form 5b Service Sites
Services Provided Modified 1600 1600 0 Form 5a Services Provided
Staffing Profile Modified 1600 3200 0 Form 2 Staffing Profile
Supplemental Line Item Budget New 1600 800 0 Form and Instruction 1 Supplemental Line Item Budget
The Health Center Program Application Forms Removed 0 0 0 Form 0285-8 Health Center Affiliation Certification
The Health Center Program Application Forms Removed 0 0 0 Form 0285- Assurances Assurances
The Health Center Program Application Forms Removed 0 0 0 Form 0285-Project Impact Capital Improvement_Investment Project Impact
The Health Center Program Application Forms Removed 0 0 0 Form 0285-Business Plan-BPR Business Plan- Non Competing
The Health Center Program Application Forms Removed 0 0 0 Form 0285-1a Planning Grant-General Info Worksheet
Verification Checklist New 200 100 0 Form 1 Verification Checklist
Total burden requested under this ICR: 32450 44825 0  
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