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
Form and Instruction 2
Checklist for Adding New Service Unchanged 450 900 0 Form and Instruction 2
Form and Instruction 2E
Checklist for Adding a New Target Population Unchanged 100 200 0 Form and Instruction 4
Form and Instruction 4E
Checklist for Adding a new Service Delivery Site Unchanged 1480 2960 0 Form and Instruction 3
Form and Instruction 3E
Checklist for Deleting Existing Service Unchanged 500 1000 0 Form and Instruction 5
Form and Instruction 5E
Checklist for Deleting Existing Service Delivery Site Unchanged 750 1500 0 Form and Instruction 6
Form and Instruction 6E
Clinical Performance Measures Unchanged 1058 3703 0 Form and Instruction 7
Form and Instruction 7E
Diabetes Action Plan - Quarterly Report Template Unchanged 4232 8464 0 Form and Instruction 8
Equipment List Unchanged 1375 1375 0 Form and Instruction 9
Expanded Services Unchanged 996 996 0 Form and Instruction 10
Form and Instruction 10E
FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting Unchanged 4125 4125 0 Form and Instruction 28
FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Unchanged 182 182 0 Form and Instruction 29
Federal Object Class Categories Unchanged 735 184 0 Form and Instruction 11
Financial Performance Measures Unchanged 1058 1587 0 Form and Instruction 12
Form and Instruction 12E
Form 12: Organization Contacts Unchanged 1058 529 0 Form and Instruction 26
Form and Instruction 26E
Form 1A: General Information Worksheet Unchanged 1058 1058 0 Form and Instruction 13
Form and Instruction 13E
Form 1B: BPHC Funding Request Summary Unchanged 1000 750 0 Form and Instruction 14
Form and Instruction 14E
Form 1C: Documents on File Unchanged 1058 529 0 Form and Instruction 15
Form and Instruction 15E
Form 2: Staffing Profile Unchanged 1058 1058 0 Form and Instruction 16
Form and Instruction 16E
Form 3: Income Analysis Unchanged 1058 1058 0 Form and Instruction 17E
Form and Instruction 17
Form 3A: FQHC Look-Alike Budget Information Unchanged 50 50 0 Form and Instruction 18
Form and Instruction 18E
Form 4: Community Characteristics Unchanged 1058 1058 0 Form and Instruction 19
Form and Instruction 19E
Form 5A: Services Provided Unchanged 1058 1058 0 Form and Instruction 20
Form and Instruction 20E
Form 5B: Service Sites Unchanged 1508 1508 0 Form and Instruction 21
Form and Instruction 21E
Form 5C: Other Activities/Locations Unchanged 1058 529 0 Form and Instruction 22
Form and Instruction 22E
Form 6A: Current Board Member Characteristics Unchanged 1058 1058 0 Form and Instruction 23
Form and Instruction 23E
Form 6B: Request for Waiver of Governance Requirements Unchanged 1058 1058 0 Form and Instruction 24
Form and Instruction 24E
Form 8: Health Center Agreements Unchanged 1058 1058 0 Form and Instruction 25
Form and Instruction 25E
Funding Sources Unchanged 735 368 0 Form and Instruction 27
HRSA EHBs Action Plan Unchanged 4232 4232 0 Form and Instruction 33
HRSA Loan Guarantee Program Application Unchanged 20 20 0 Form and Instruction 34
Health Center Controlled Networks (HCCN) Progress Report Table Unchanged 90 90 0 Form and Instruction 30
Form and Instruction 30E
Health Center Program Progress Report Unchanged 735 735 0 Form and Instruction 31
Form and Instruction 31E
Health Center Program: Supplemental Information Unchanged 500 500 0 Form and Instruction 32
Form and Instruction 32E
Operational Plan Unchanged 500 1500 0 Form and Instruction 35
Form and Instruction 35E
Other Requirements for Sites Unchanged 600 300 0 Form and Instruction 36
Participating Health Center List Unchanged 90 90 0 Form and Instruction 37
Patient Target and Calculations Unchanged 1058 1058 0 Form and Instruction 38
Program Specific Forms Instructions Unchanged 1500 1500 0 Form and Instruction 39
Form and Instruction 39E
Project Narrative Update Unchanged 883 3532 0 Form and Instruction 40
Form and Instruction 40E
Project Overview Unchanged 182 182 0 Form and Instruction 41
Project Plan Unchanged 546 819 0 Form and Instruction 42
Project Qualification Criteria Unchanged 735 735 0 Form and Instruction 43
Project Work Plan Unchanged 135 540 0 Form and Instruction 44
Form and Instruction 44E
Proposal Cover Page Unchanged 735 735 0 Form and Instruction 45
Summary Page Unchanged 1558 779 0 Form and Instruction 46
Form and Instruction 46E
Total burden requested under this ICR: 48063 59242 0  
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