Information Collection List

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