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Agenda
Reg Review
ICR
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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