Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Applicant Qualification Criteria Form New 500 500 0 Form and Instruction 13 Applicant Qualification Criteria Form
Capital Semi Annual Progress Report New 2634 2634 0 Form and Instruction 9a Capital Semi Annual Progress Report
Capital Semi-Annual Progress Report Removed 0 0 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 Removed 0 0 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 Removed 0 0 0 Form and Instruction 8 Diabetes Action Plan Quarterly Report.docx
Equipment List Modified 1375 688 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 Removed 0 0 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 Unchanged 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
FY 2022 Accelerating Cancer Screening Progress Report New 10 15 0 Form and Instruction 13 FY 2022 Accelerating Cancer Screening Progress Report
Federal Object Class Categories Unchanged 735 184 0 Form and Instruction 11 Federal Object Class Category Form- clean.docx
Financial Performance Indicators Modified 20 20 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 1058 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 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 Unchanged 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 1058 1058 0 Form and Instruction 21 Form 5B - clean.docx
Form and Instruction 21E Form 5B - edits.docx
Form 5C: Other Activities/Locations Modified 1058 1058 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 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 Modified 1058 1058 0 Form and Instruction 25 Form 8 - Clean.docx
Form and Instruction 25E Form 8 - edits.docx
Funding Request Summary Form (SBHC) New 500 250 0 Form and Instruction 15 Funding Request Summary Form
Funding Sources Unchanged 735 368 0 Form and Instruction 27 Funding Sources - clean.docx
HRSA EHBs Action Plan Removed 0 0 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 Modified 90 90 0 Form and Instruction 10a HCCN Progress Report
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 Removed 0 0 0 Form and Instruction 32 Health Center Program Supplemental Information - Clean.docx
Form and Instruction 32E Health Center Program Supplemental Information - Clean.docx
NHHCIA NCC Clinical Performance Measures New 6 9 0 Form and Instruction 3a NHHCIA NCC Clinical Performance Measures
NHHCIA NCC Financial Performance Measures New 6 3 0 Form and Instruction 4a NHHCIA NCC Financial Performance Measures
NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update New 18 3 0 Form and Instruction 6a NHHCIA NCC Income Analysis Form
Form and Instruction 6b NHHCIA NCC Project Work Plan Progress Report
Form and Instruction 6c NHHCIA NCC Project Work Plan Update
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 Impact Form New 500 500 0 Form and Instruction 7a Patient Impact Form
Patient Target and Calculations Unchanged 1058 1058 0 Form and Instruction 38 Patient Target and Calculation.docx
Program Specific Forms Instructions Removed 0 0 0 Form and Instruction 39 Program Specific Form Instructions Clean.docx
Form and Instruction 39E Program Specific Form Instructions Edits.docx
Progress Report Non-Capital Investment New 5600 8400 0 Form and Instruction 7a Progress Report- Non-Capital Investments
Project Cover Page New 735 735 0 Form and Instruction 12 Proposal Cover Page
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 500 500 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 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
QIF Evaluative Measures Report New 12 18 0 Form and Instruction 11 QIF Evaluative Measures Report
QIF Progress Report New 12 18 0 Form and Instruction 1a QIF Progress Report
QIF Project Plan Form New 100 100 0 Form and Instruction 2a QIF Project Plan Form
Summary Page Modified 950 725 0 Form and Instruction 46 Summary Page - clean.docx
Form and Instruction 46E Summary Page - edits.docx
Total burden requested under this ICR: 39279 46529 0  
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