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
Checklist for Adding New Service Modified 700 1400 0 Form 1
Checklist for Adding a New Target Population Modified 50 50 0 Form 1
Checklist for Adding a new Service Delivery Site Modified 700 1400 0 Form 1
Checklist for Deleting Existing Service Modified 700 1400 0 Form 1
Checklist for Deleting Existing Service Delivery Site Modified 700 1400 0 Form 1
Checklist for Replacing Existing Service Delivery Site Modified 700 1400 0 Form 1
Clinical Performance Measures Modified 1600 3200 0 Form 1
Community Characteristics Modified 650 650 0 Form 4
Current Board Member Characteristics Modified 1600 1600 0 Form 6a
Documents on File Modified 650 650 0 Form 1C
EHR Readiness Checklist Modified 50 25 0 Form 1
Equipment List Modified 400 400 0 Form 1
Financial Performance Measures Modified 1600 1600 0 Form 1
Funding Request Summary Modified 400 400 0 Form 1B
Funding Sources Modified 400 200 0 Form 1
General Information Worksheet Modified 1700 3400 0 Form 1
Health Center Agreements Modified 250 250 0 Form 8
Implementation Plan Modified 400 1200 0 Form 1
Income Analysis Modified 1600 4800 0 Form 3
Increased Demand for Services Modified 1200 1200 0 Form 1
Look Alike Budget Modified 100 100 0 Form 1
Need for Assitance Worksheet Modified 650 3250 0 Form 9
Oamp;E Progress Report Modified 1295 1295 0 Form 1
Oamp;E Supplemental Modified 1295 1295 0 Form 1
Organization Contacts Modified 1600 800 0 Form 12
Other Activities/Locations Modified 1600 800 0 Form 5c
Other Requirements for Sites Modified 400 200 0 Form 1
Project Cover Page Modified 400 400 0 Form 1
Project Qualification Criteria Modified 400 400 0 Form 1
Project Work Plan Modified 100 400 0 Form 1
Proposal Cover Page Modified 400 400 0 Form 1
Request for Waiver of Governance Requirements Modified 150 150 0 Form 6b
Service Sites Modified 1600 1600 0 Form 5b
Services Provided Modified 1600 1600 0 Form 5a
Staffing Profile Modified 1600 3200 0 Form 2
Supplemental Line Item Budget Modified 1600 800 0 Form and Instruction 1
Verification Checklist Modified 200 100 0 Form 1
Total burden requested under this ICR: 32640 45015 0  
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