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
Checklist for Adding New Service Unchanged 700 1400 0 Form 1
Checklist for Adding a New Target Population Unchanged 50 50 0 Form 1
Checklist for Adding a new Service Delivery Site Unchanged 700 1400 0 Form 1
Checklist for Deleting Existing Service Unchanged 700 1400 0 Form 1
Checklist for Deleting Existing Service Delivery Site Unchanged 700 1400 0 Form 1
Checklist for Replacing Existing Service Delivery Site Unchanged 700 1400 0 Form 1
Clinical Performance Measures Unchanged 1600 3200 0 Form 1
Community Characteristics Unchanged 650 650 0 Form 4
Current Board Member Characteristics Unchanged 1600 1600 0 Form 6a
Documents on File Unchanged 650 650 0 Form 1C
EHR Readiness Checklist Unchanged 50 25 0 Form 1
Equipment List Unchanged 400 400 0 Form 1
Financial Performance Measures Unchanged 1600 1600 0 Form 1
Funding Request Summary Unchanged 400 400 0 Form 1B
Funding Sources Unchanged 400 200 0 Form 1
General Information Worksheet Unchanged 1700 3400 0 Form 1
Health Center Agreements Unchanged 250 250 0 Form 8
Implementation Plan Unchanged 400 1200 0 Form 1
Income Analysis Unchanged 1600 4800 0 Form 3
Increased Demand for Services Unchanged 1200 1200 0 Form 1
Look Alike Budget Unchanged 100 100 0 Form 1
Need for Assitance Worksheet Unchanged 650 3250 0 Form 9
Oamp;E Progress Report Modified 1200 1200 0 Form 1
Oamp;E Supplemental Modified 1200 1200 0 Form 1
Organization Contacts Unchanged 1600 800 0 Form 12
Other Activities/Locations Unchanged 1600 800 0 Form 5c
Other Requirements for Sites Unchanged 400 200 0 Form 1
Project Cover Page Unchanged 400 400 0 Form 1
Project Qualification Criteria Unchanged 400 400 0 Form 1
Project Work Plan Unchanged 100 400 0 Form 1
Proposal Cover Page Unchanged 400 400 0 Form 1
Request for Waiver of Governance Requirements Unchanged 150 150 0 Form 6b
Service Sites Unchanged 1600 1600 0 Form 5b
Services Provided Unchanged 1600 1600 0 Form 5a
Staffing Profile Unchanged 1600 3200 0 Form 2
Supplemental Line Item Budget Unchanged 1600 800 0 Form and Instruction 1
Verification Checklist Unchanged 200 100 0 Form 1
Total burden requested under this ICR: 32450 44825 0  
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