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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Capital Semi-Annual Progress Report
Unchanged
1992
1992
0
Form and Instruction
1
Capital Semi Annual Progress Report (SAPR).docx
Form and Instruction
2
Progress Report COVID Mark Up_5.26.20.pdf
Checklist for Adding New Service
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
4232
8464
0
Form and Instruction
8
Diabetes Action Plan Quarterly Report.docx
Equipment List
Unchanged
1375
1375
0
Form and Instruction
9
Equipment List
Expanded Services
Unchanged
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
Unchanged
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
Form and Instruction
29
Progress Report PCHP Mark Up_add new report 10.30.20.docx
Federal Object Class Categories
Unchanged
735
184
0
Form and Instruction
11
Federal Object Class Category Form- clean.docx
Financial Performance Measures
Unchanged
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
Unchanged
1058
529
0
Form and Instruction
26
Form 12 - Clean.docx
Form and Instruction
26E
Form 12 - edits.docx
Form 1A: General Information Worksheet
Unchanged
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
Unchanged
1000
750
0
Form and Instruction
14
Form 1B - clean.docx
Form and Instruction
14E
Form 1B - edits.DOCX
Form 1C: Documents on File
Unchanged
1058
529
0
Form and Instruction
15
Form 1C - clean.docx
Form and Instruction
15E
Form 1C edits.docx
Form 2: Staffing Profile
Unchanged
1058
1058
0
Form and Instruction
16
Form 2 - clean.docx
Form and Instruction
16E
Form 2 - edits.docx
Form 3: Income Analysis
Unchanged
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
Unchanged
50
50
0
Form and Instruction
18
Form 3A - clean.docx
Form and Instruction
18E
Form 3A - edits.docx
Form 4: Community Characteristics
Unchanged
1058
1058
0
Form and Instruction
19
Form 4 - Clean.docx
Form and Instruction
19E
Form 4 - edits.docx
Form 5A: Services Provided
Unchanged
1058
1058
0
Form and Instruction
20
Form 5A - clean.docx
Form and Instruction
20E
Form 5A - edits.docx
Form 5B: Service Sites
Unchanged
1508
1508
0
Form and Instruction
21
Form 5B - clean.docx
Form and Instruction
21E
Form 5B - edits.docx
Form 5C: Other Activities/Locations
Unchanged
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
Unchanged
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
Unchanged
1058
1058
0
Form and Instruction
24
Form 6B - Clean.docx
Form and Instruction
24E
Form 6B - edits.docx
Form 8: Health Center Agreements
Unchanged
1058
1058
0
Form and Instruction
25
Form 8 - Clean.docx
Form and Instruction
25E
Form 8 - edits.docx
Funding Sources
Unchanged
735
368
0
Form and Instruction
27
Funding Sources - clean.docx
HRSA EHBs Action Plan
Unchanged
4232
4232
0
Form and Instruction
33
HRSA EHBs Action Plan.docx
HRSA Loan Guarantee Program Application
Unchanged
20
20
0
Form and Instruction
34
HRSA Loan Guarantee Program Application.docx
Health Center Controlled Networks (HCCN) Progress Report Table
Unchanged
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
Unchanged
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
Unchanged
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
Unchanged
500
1500
0
Form and Instruction
35
Operational Plan - clean.docx
Form and Instruction
35E
Operational Plan - edits.docx
Other Requirements for Sites
Unchanged
600
300
0
Form and Instruction
36
Other Requirements for Sites
Participating Health Center List
Unchanged
90
90
0
Form and Instruction
37
Participating Health Centers List.docx
Patient Target and Calculations
Unchanged
1058
1058
0
Form and Instruction
38
Patient Target and Calculation.docx
Program Specific Forms Instructions
Unchanged
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
Unchanged
883
3532
0
Form and Instruction
40
Project Narrative Update - clean.docx
Form and Instruction
40E
Project Narrative Update - edits.docx
Project Overview
Unchanged
182
182
0
Form and Instruction
41
Project Overview.docx
Project Plan
Unchanged
546
819
0
Form and Instruction
42
Project Plan.docx
Project Qualification Criteria
Unchanged
735
735
0
Form and Instruction
43
Project Qualification Criteria.docx
Project Work Plan
Unchanged
135
540
0
Form and Instruction
44
Project Work Plan - clean.docx
Form and Instruction
44E
Project Work Plan - edits.docx
Proposal Cover Page
Unchanged
735
735
0
Form and Instruction
45
Proposal Cover Page.docx
Summary Page
Unchanged
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
To view an IC, click on IC Title