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
Capital Semi Annual Progress Report New 2634 2634 0 Form and Instruction 9a
Capital Semi-Annual Progress Report Removed 0 0 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 Removed 0 0 0 Form and Instruction 7
Form and Instruction 7E
Diabetes Action Plan - Quarterly Report Template Removed 0 0 0 Form and Instruction 8
Equipment List Modified 1375 688 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 Removed 0 0 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
Form and Instruction 29
FY 2022 Accelerating Cancer Screening Progress Report New 10 15 0 Form and Instruction 13
Federal Object Class Categories Unchanged 735 184 0 Form and Instruction 11
Financial Performance Indicators Modified 20 20 0 Form and Instruction 12
Form and Instruction 12E
Form 12: Organization Contacts Modified 1058 1058 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 Modified 1000 750 0 Form and Instruction 14
Form and Instruction 14E
Form 1C: Documents on File Modified 1058 529 0 Form and Instruction 15
Form and Instruction 15E
Form 2: Staffing Profile Modified 1058 1058 0 Form and Instruction 16
Form and Instruction 16E
Form 3: Income Analysis Modified 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 Modified 1058 1058 0 Form and Instruction 19
Form and Instruction 19E
Form 5A: Services Provided Modified 1058 1058 0 Form and Instruction 20
Form and Instruction 20E
Form 5B: Service Sites Modified 1058 1058 0 Form and Instruction 21
Form and Instruction 21E
Form 5C: Other Activities/Locations Modified 1058 1058 0 Form and Instruction 22
Form and Instruction 22E
Form 6A: Current Board Member Characteristics Modified 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 Modified 1058 1058 0 Form and Instruction 25
Form and Instruction 25E
Funding Request Summary Form (SBHC) New 500 250 0 Form and Instruction 15
Funding Sources Unchanged 735 368 0 Form and Instruction 27
HRSA EHBs Action Plan Removed 0 0 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 Modified 90 90 0 Form and Instruction 10a
Health Center Program Progress Report Unchanged 735 735 0 Form and Instruction 31
Form and Instruction 31E
Health Center Program: Supplemental Information Removed 0 0 0 Form and Instruction 32
Form and Instruction 32E
NHHCIA NCC Clinical Performance Measures New 6 9 0 Form and Instruction 3a
NHHCIA NCC Financial Performance Measures New 6 3 0 Form and Instruction 4a
NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update New 18 3 0 Form and Instruction 6a
Form and Instruction 6b
Form and Instruction 6c
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 Impact Form New 500 500 0 Form and Instruction 7a
Patient Target and Calculations Unchanged 1058 1058 0 Form and Instruction 38
Program Specific Forms Instructions Removed 0 0 0 Form and Instruction 39
Form and Instruction 39E
Progress Report Non-Capital Investment New 5600 8400 0 Form and Instruction 7a
Project Cover Page New 735 735 0 Form and Instruction 12
Project Narrative Update Modified 883 3532 0 Form and Instruction 40
Form and Instruction 40E
Project Overview Modified 500 500 0 Form and Instruction 41
Project Plan Modified 546 819 0 Form and Instruction 42
Project Qualification Criteria Modified 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
QIF Evaluative Measures Report New 12 18 0 Form and Instruction 11
QIF Progress Report New 12 18 0 Form and Instruction 1a
QIF Project Plan Form New 100 100 0 Form and Instruction 2a
Summary Page Modified 950 725 0 Form and Instruction 46
Form and Instruction 46E
Total burden requested under this ICR: 39279 46529 0  
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