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
Form 10
Checklist for Adding New Service Modified 700 700 0 Form and Instruction 31
Form and Instruction 31
Checklist for Adding a New Target Population Modified 50 25 0 Form and Instruction 33
Checklist for Adding a new Service Delivery Site Modified 700 1050 0 Form and Instruction 29
Form and Instruction 29
Checklist for Deleting Existing Service Modified 700 700 0 Form and Instruction 32
Form and Instruction 32
Checklist for Deleting Existing Service Delivery Site Modified 700 700 0 Form and Instruction 30
Form and Instruction 30
Checklist for Replacing Existing Service Delivery Site Removed 0 0 0 Form 1
Clinical Performance Measures Modified 1000 3500 0 Form 17
Form 17
Community Characteristics Modified 1000 1000 0 Form 4
Form 4
Current Board Member Characteristics Modified 1000 500 0 Form 6A
Form 6A
Documents on File Modified 1000 500 0 Form 1C
EHR Readiness Checklist Removed 0 0 0 Form 1
Equipment List Modified 400 400 0 Form and Instruction 23
Form and Instruction 23
Expanded Services Modified 1400 1400 0 Form and Instruction 34
Form and Instruction 34
Federal Object Class Categories New 1400 350 0 Form and Instruction 35
Form and Instruction 35
Financial Performance Measures Modified 1000 1000 0 Form 18
Instruction
Funding Request Summary Modified 450 338 0 Form 1B
Form 1B
Funding Sources Modified 400 200 0 Form and Instruction 25
Form and Instruction 25
General Information Worksheet Modified 1700 1700 0 Form 1A
Instruction
Health Center Agreements Modified 600 450 0 Form and Instruction 8
Form and Instruction 8
Health Center Controlled Networks Progress Report New 93 2325 0 Form 40
Form 40
Health Center Controlled Networks Work Plan New 93 465 0 Form 41
Form 41
Implementation Plan Modified 900 2700 0 Form 19
Form 19
Instruction
Income Analysis Modified 2000 4850 0 Form 3
Form 3
Form and Instruction 3A
Form and Instruction 3A
Look Alike Budget Removed 0 0 0 Form 1
Need for Assitance Worksheet Modified 500 2250 0 Form 9
Form 9
O & E Progress Report Modified 1200 1200 0 Form and Instruction 28
Form and Instruction 28
O & E Supplemental Modified 1200 1200 0 Form and Instruction 27
Form and Instruction 27
Organization Contacts Modified 1000 500 0 Form 12
Form 12
Other Activities/Locations Modified 1000 500 0 Form 5C
Form 5C
Other Requirements for Sites Modified 400 200 0 Form and Instruction 24
Form and Instruction 24
Program Narrative Update New 900 3600 0 Form and Instruction 38
Project Cover Page Modified 400 400 0 Form and Instruction 22
Project Qualification Criteria Modified 400 400 0 Form and Instruction 26
Form and Instruction 26
Project Work Plan Modified 200 1000 0 Form and Instruction 20
Form and Instruction 20
Proposal Cover Page Modified 400 400 0 Form and Instruction 21
Form and Instruction 21
Request for Waiver of Governance Requirements Modified 100 100 0 Form and Instruction 6B
Form and Instruction 6B
Service Sites Modified 1200 900 0 Form 5B
Services Provided Modified 1700 1700 0 Form 5A
Form 5A
Staffing Profile Modified 1700 1700 0 Form 2
Form 2
Substance Abuse Progress Report New 1200 1200 0 Form and Instruction 39
Summary Page New 1700 425 0 Form 37
Supplemental Information Modified 2000 1000 0 Form and Instruction 36
Verification Checklist Removed 0 0 0 Form 1
Zika Progress Report New 80 80 0 Form and Instruction 42
Total burden requested under this ICR: 35566 44608 0  
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