Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Annual Emergency Preparedness Report Modified 1000 1000 0 Form 10 Emergency Preparedness Report
Form 10 Emergency Preparedness Report Final
Checklist for Adding New Service Modified 700 700 0 Form and Instruction 31 Checklist for Adding New Service - track changes
Form and Instruction 31 Checklist for Adding New Service 2017 Final
Checklist for Adding a New Target Population Modified 50 25 0 Form and Instruction 33 Checklist for Adding a New Target Population - track changes
Checklist for Adding a new Service Delivery Site Modified 700 1050 0 Form and Instruction 29 Checklist for Adding a New Service Delivery Site - track changes
Form and Instruction 29 Checklist for Adding a New Service Delivery Site 2017 Final
Checklist for Deleting Existing Service Modified 700 700 0 Form and Instruction 32 Checklist for Deleting Existing Service - track changes.docx
Form and Instruction 32 Checklist for Deleting Existing Service 2017 Final
Checklist for Deleting Existing Service Delivery Site Modified 700 700 0 Form and Instruction 30 Checklist for Deleting Existing Service Delivery Site - track changes
Form and Instruction 30 Checklist for Deleting Existing Service Delivery Site 2017 Final
Checklist for Replacing Existing Service Delivery Site Removed 0 0 0 Form 1 Checklist for replacing existing service delivery site
Clinical Performance Measures Modified 1000 3500 0 Form 17 Clinical Performance Measures (track changes)
Form 17 Clinical Performance Measures Final
Community Characteristics Modified 1000 1000 0 Form 4 Community Characteristics
Form 4 Community Characteristics Final
Current Board Member Characteristics Modified 1000 500 0 Form 6A Current Board Member Characteristics
Form 6A Current Board Member Characteristics Final
Documents on File Modified 1000 500 0 Form 1C Documents on File
EHR Readiness Checklist Removed 0 0 0 Form 1 EHR Readiness Checklist
Equipment List Modified 400 400 0 Form and Instruction 23 Equipment List (track changes)
Form and Instruction 23 Equipment List Final
Expanded Services Modified 1400 1400 0 Form and Instruction 34 Expanded Services
Form and Instruction 34 Increased Demand for Services (track changes)
Federal Object Class Categories New 1400 350 0 Form and Instruction 35 Federal Object Class Categories 2017
Form and Instruction 35 Supplemental Line_Item_Budget (track changes).docx
Financial Performance Measures Modified 1000 1000 0 Form 18 Financial Performance Measures (track changes)
Instruction
Funding Request Summary Modified 450 338 0 Form 1B BPHC Funding Request Summary
Form 1B BPHC Funding Request Summary Final
Funding Sources Modified 400 200 0 Form and Instruction 25 Funding Sources (track changes)
Form and Instruction 25 Funding Sources 2017 Final
General Information Worksheet Modified 1700 1700 0 Form 1A General Information Worksheet
Instruction
Health Center Agreements Modified 600 450 0 Form and Instruction 8 Health Center Agreements
Form and Instruction 8 Health Center Agreements Final
Health Center Controlled Networks Progress Report New 93 2325 0 Form 40 HCCN Progress Report (track changes)
Form 40 HCCN Progress Report Final
Health Center Controlled Networks Work Plan New 93 465 0 Form 41 HCCN Work Plan (track changes)
Form 41 HCCN Work Plan 2016 Cohort.pdf
Implementation Plan Modified 900 2700 0 Form 19 Implementation Plan (track changes)
Form 19 Implementation plan 2017 Final
Instruction
Income Analysis Modified 2000 4850 0 Form 3 Income Analysis
Form 3 Income Analysis Final
Form and Instruction 3A Look alike Budget
Form and Instruction 3A Look Alike Budget Information Final
Look Alike Budget Removed 0 0 0 Form 1 Look Alike Budget
Need for Assitance Worksheet Modified 500 2250 0 Form 9 Need for Assistance Worksheet
Form 9 Need for Assistance Worksheet Final
O & E Progress Report Modified 1200 1200 0 Form and Instruction 28 OE Progress_Report (track changes)
Form and Instruction 28 OE Progress_Report 2017 Final
O & E Supplemental Modified 1200 1200 0 Form and Instruction 27 Outreach and Enrollment Supplemental form (track changes).docx
Form and Instruction 27 Outreach and Enrollment Supplemental 2017 Final
Organization Contacts Modified 1000 500 0 Form 12 Organization Contacts
Form 12 Organization Contacts Final
Other Activities/Locations Modified 1000 500 0 Form 5C Other Activities/Locations
Form 5C Other Activities/Locations Final
Other Requirements for Sites Modified 400 200 0 Form and Instruction 24 Other requirement for sites (track changes)
Form and Instruction 24 Other requirement for sites 2017 Final
Program Narrative Update New 900 3600 0 Form and Instruction 38 Program Narrative Update 2017
Project Cover Page Modified 400 400 0 Form and Instruction 22 Project Cover Page (track changes)
Project Qualification Criteria Modified 400 400 0 Form and Instruction 26 Project Qualification Criteria (track changes)
Form and Instruction 26 Project Qualification Criteria 2017 Final
Project Work Plan Modified 200 1000 0 Form and Instruction 20 Project Work Plan (track changes)
Form and Instruction 20 Project Work Plan Final
Proposal Cover Page Modified 400 400 0 Form and Instruction 21 Proposal Cover Page (track changes)
Form and Instruction 21 Proposal Cover Page 2017 Final
Request for Waiver of Governance Requirements Modified 100 100 0 Form and Instruction 6B Request for Waiver of Board Member
Form and Instruction 6B Request for Waiver of Board Member Final
Service Sites Modified 1200 900 0 Form 5B Service Sites
Services Provided Modified 1700 1700 0 Form 5A Services Provided
Form 5A Services Provided Final
Staffing Profile Modified 1700 1700 0 Form 2 Staffing Profile
Form 2 Staffing Profile Final
Substance Abuse Progress Report New 1200 1200 0 Form and Instruction 39 Substance Abuse Progress Report
Summary Page New 1700 425 0 Form 37 Summary Page 2017.docx
Supplemental Information Modified 2000 1000 0 Form and Instruction 36 Supplemental 2017.docx
Verification Checklist Removed 0 0 0 Form 1 Verification Checklist
Zika Progress Report New 80 80 0 Form and Instruction 42 Zika Progress Report.pdf
Total burden requested under this ICR: 35566 44608 0  
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