Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Capital Semi-Annual Progress Report Modified 1992 1992 0 Form and Instruction 1 Capital Semi Annual Progress Report (SAPR).docx
Checklist for Adding New Service Modified 450 900 0 Form and Instruction 2 Checklist for Adding New Service -Clean.docx
Form and Instruction 2E Checklist for Adding New Service edits.docx
Checklist for Adding a New Target Population Modified 100 200 0 Form and Instruction 4 Checklist for Adding a New Target Population - Clean.docx
Form and Instruction 4E Checklist for Adding a New Target Population edits.docx
Checklist for Adding a new Service Delivery Site Modified 1480 2960 0 Form and Instruction 3 Checklist for Adding a New Service Delivery Site - Clean.docx
Form and Instruction 3E Checklist for Adding a New Service Delivery Site edits.docx
Checklist for Deleting Existing Service Modified 500 1000 0 Form and Instruction 5 Checklist for Deleting Existing Service -Clean.docx
Form and Instruction 5E Checklist for Deleting Existing Service - edits.docx
Checklist for Deleting Existing Service Delivery Site Modified 750 1500 0 Form and Instruction 6 Checklist for Deleting Existing Service Delivery Site - Clean.docx
Form and Instruction 6E Checklist for Deleting Existing Service Delivery Site edits.docx
Clinical Performance Measures Modified 1058 3703 0 Form and Instruction 7 Clinical Performance Measures Clean.docx
Form and Instruction 7E Clinical Performance Measures edits.docx
Diabetes Action Plan - Quarterly Report Template Modified 4232 8464 0 Form and Instruction 8 Diabetes Action Plan Quarterly Report.docx
Equipment List Modified 1375 1375 0 Form and Instruction 9 Equipment List
Expanded Services Modified 996 996 0 Form and Instruction 10 Expanded Services Clean.docx
Form and Instruction 10E Expanded Services - edits.docx
FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting Modified 4125 4125 0 Form and Instruction 28 FY2018 Expanding Access to Quality SUD-MH IBHS Progress Reporting.docx
FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Modified 182 182 0 Form and Instruction 29 FY2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting.docx
Federal Object Class Categories Modified 735 184 0 Form and Instruction 11 Federal Object Class Category Form- clean.docx
Financial Performance Measures Modified 1058 1587 0 Form and Instruction 12 Financial Performance Measures - clean.docx
Form and Instruction 12E Financial Performance Measures - edits.docx
Form 12: Organization Contacts Modified 1058 529 0 Form and Instruction 26 Form 12 - Clean.docx
Form and Instruction 26E Form 12 - edits.docx
Form 1A: General Information Worksheet New 1058 1058 0 Form and Instruction 13 Form 1A - clean.docx
Form and Instruction 13E Form 1A - edits.docx
Form 1B: BPHC Funding Request Summary Modified 1000 750 0 Form and Instruction 14 Form 1B - clean.docx
Form and Instruction 14E Form 1B - edits.DOCX
Form 1C: Documents on File Modified 1058 529 0 Form and Instruction 15 Form 1C - clean.docx
Form and Instruction 15E Form 1C edits.docx
Form 2: Staffing Profile Modified 1058 1058 0 Form and Instruction 16 Form 2 - clean.docx
Form and Instruction 16E Form 2 - edits.docx
Form 3: Income Analysis Modified 1058 1058 0 Form and Instruction 17E Form 3 - edits.docx
Form and Instruction 17 Form 3 - clean.docx
Form 3A: FQHC Look-Alike Budget Information New 50 50 0 Form and Instruction 18 Form 3A - clean.docx
Form and Instruction 18E Form 3A - edits.docx
Form 4: Community Characteristics Modified 1058 1058 0 Form and Instruction 19 Form 4 - Clean.docx
Form and Instruction 19E Form 4 - edits.docx
Form 5A: Services Provided Modified 1058 1058 0 Form and Instruction 20 Form 5A - clean.docx
Form and Instruction 20E Form 5A - edits.docx
Form 5B: Service Sites Modified 1508 1508 0 Form and Instruction 21 Form 5B - clean.docx
Form and Instruction 21E Form 5B - edits.docx
Form 5C: Other Activities/Locations Modified 1058 529 0 Form and Instruction 22 Form 5C - Clean.docx
Form and Instruction 22E Form 5C - edits.docx
Form 6A: Current Board Member Characteristics Modified 1058 1058 0 Form and Instruction 23 Form 6A - Clean.docx
Form and Instruction 23E Form 6A - edits.docx
Form 6B: Request for Waiver of Governance Requirements Modified 1058 1058 0 Form and Instruction 24 Form 6B - Clean.docx
Form and Instruction 24E Form 6B - edits.docx
Form 8: Health Center Agreements Modified 1058 1058 0 Form and Instruction 25 Form 8 - Clean.docx
Form and Instruction 25E Form 8 - edits.docx
Funding Sources Modified 735 368 0 Form and Instruction 27 Funding Sources - clean.docx
HRSA EHBs Action Plan Modified 4232 4232 0 Form and Instruction 33 HRSA EHBs Action Plan.docx
HRSA Loan Guarantee Program Application Modified 20 20 0 Form and Instruction 34 HRSA Loan Guarantee Program Application.docx
Health Center Controlled Networks (HCCN) Progress Report Table Modified 90 90 0 Form and Instruction 30 HCCN Progress Report - clean.docx
Form and Instruction 30E HCCN Progress Report -edits.docx
Health Center Program Progress Report Modified 735 735 0 Form and Instruction 31 Health Center Program Progress Report - Clean.docx
Form and Instruction 31E Health Center Program Progress Report - edits.docx
Health Center Program: Supplemental Information Modified 500 500 0 Form and Instruction 32 Health Center Program Supplemental Information - Clean.docx
Form and Instruction 32E Health Center Program Supplemental Information - Clean.docx
Operational Plan Modified 500 1500 0 Form and Instruction 35 Operational Plan - clean.docx
Form and Instruction 35E Operational Plan - edits.docx
Other Requirements for Sites Modified 600 300 0 Form and Instruction 36 Other Requirements for Sites
Participating Health Center List New 90 90 0 Form and Instruction 37 Participating Health Centers List.docx
Patient Target and Calculations New 1058 1058 0 Form and Instruction 38 Patient Target and Calculation.docx
Program Specific Forms Instructions New 1500 1500 0 Form and Instruction 39 Program Specific Form Instructions Clean.docx
Form and Instruction 39E Program Specific Form Instructions Edits.docx
Project Narrative Update Modified 883 3532 0 Form and Instruction 40 Project Narrative Update - clean.docx
Form and Instruction 40E Project Narrative Update - edits.docx
Project Overview Modified 182 182 0 Form and Instruction 41 Project Overview.docx
Project Plan Modified 546 819 0 Form and Instruction 42 Project Plan.docx
Project Qualification Criteria Modified 735 735 0 Form and Instruction 43 Project Qualification Criteria.docx
Project Work Plan Modified 135 540 0 Form and Instruction 44 Project Work Plan - clean.docx
Form and Instruction 44E Project Work Plan - edits.docx
Proposal Cover Page Modified 735 735 0 Form and Instruction 45 Proposal Cover Page.docx
Summary Page Modified 1558 779 0 Form and Instruction 46 Summary Page - clean.docx
Form and Instruction 46E Summary Page - edits.docx
Total burden requested under this ICR: 48063 59242 0  
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