Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
2026 Grant Number Form New 400 100 0 Form and Instruction 23
Applicant Qualification Criteria Form Removed 0 0 0 Form and Instruction 13
Capital Semi Annual Progress Report Modified 1000 1000 0 Form and Instruction 1
Checklist for Adding Care in a Transitional Care in Carceral Setting Site to Scope New 50 50 0 Form and Instruction 50
Checklist for Adding New Service Modified 450 900 0 Form and Instruction 2
Checklist for Adding a New Target Population Removed 0 0 0 Form and Instruction 4
Form and Instruction 4E
Checklist for Adding a new Service Delivery Site Modified 1480 2960 0 Form and Instruction 3
Checklist for Deleting Existing Service Modified 500 1000 0 Form and Instruction 4
Checklist for Deleting Existing Service Delivery Site Modified 750 1500 0 Form and Instruction 5
Checklist for Form 5A Scope Adjustments New 1875 938 0 Form and Instruction 51
Checklist for Form 5B Scope Adjustments New 1695 848 0 Form and Instruction 52
Equipment List Modified 130 65 0 Form and Instruction 6
FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Removed 0 0 0 Form and Instruction 29
Form and Instruction 29
FY 2022 Accelerating Cancer Screening Progress Report Modified 29 44 0 Form and Instruction 22
Federal Object Class Categories Modified 500 125 0 Form and Instruction 7
Form 12: Organization Contacts Modified 970 485 0 Form and Instruction 20
Form 1A: General Information Worksheet Modified 1370 1028 0 Form and Instruction 9
Form 1B: BPHC Funding Request Summary Modified 900 675 0 Form and Instruction 10
Form 1C: Documents on File Modified 1460 730 0 Form and Instruction 11
Form 2: Staffing Profile Modified 1370 1370 0 Form and Instruction 12
Form 3: Income Analysis Modified 1370 1370 0 Form and Instruction 13
Form 3A: FQHC Look-Alike Budget Information Removed 0 0 0 Form and Instruction 18
Form and Instruction 18E
Form 4: Community Characteristics Removed 0 0 0 Form and Instruction 19
Form and Instruction 19E
Form 5A: Services Provided Modified 1428 357 0 Form and Instruction 14
Form 5B: Sites Modified 1428 357 0 Form and Instruction 15
Form 5C: Other Activities/Locations Modified 550 138 0 Form and Instruction 16
Form 6A: Current Board Member Characteristics Modified 1370 1370 0 Form and Instruction 17
Form 6B: Request for Waiver of Board Member Requirements Modified 1370 1370 0 Form and Instruction 18
Form 8: Health Center Agreements Modified 1370 1370 0 Form and Instruction 19
Funding Request Summary Form (SBHC) Removed 0 0 0 Form and Instruction 15
Funding Sources Modified 130 65 0 Form and Instruction 21
HRSA Loan Guarantee Program Application Modified 5 5 0 Form and Instruction 26
Health Center Controlled Networks (HCCN) Progress Report Table Modified 50 25 0 Form and Instruction 24
Health Center Program Progress Report Modified 130 130 0 Form and Instruction 25
Impact Form Modified 400 400 0 Form and Instruction 27
LAL Cover page New 110 55 0 Form and Instruction 49
Loan Guarantee Financial Performance Indicators Modified 5 5 0 Form and Instruction 8
NH-NCC Project Work Plan Update New 5 5 0 Form and Instruction 32
NHHCIA NCC Clinical Performance Measures Modified 5 8 0 Form and Instruction 28
NHHCIA NCC Financial Performance Measures Modified 5 3 0 Form and Instruction 29
NHHCIA NCC Income Analysis Form Modified 5 1 0 Form and Instruction 30
NHHCIA Sample Project Work Plan New 2 0 0 Form and Instruction 31
Operational Plan Modified 350 700 0 Form and Instruction 33
Other Requirements for Sites Modified 130 65 0 Form and Instruction 34
Participating Health Center List Modified 90 90 0 Form and Instruction 35
Patient Impact Form Removed 0 0 0 Form and Instruction 7a
Patient Target and Calculations Removed 0 0 0 Form and Instruction 38
Progress Report Non-Capital Investment Removed 0 0 0 Form and Instruction 7a
Project Cover Page Modified 130 130 0 Form and Instruction 36
Project Narrative Update Modified 1325 5300 0 Form and Instruction 37
Project Overview Form Modified 500 500 0 Form and Instruction 38
Project Plan Removed 0 0 0 Form and Instruction 42
Project Qualification Criteria Modified 130 65 0 Form and Instruction 39
Project Work Plan Modified 508 2032 0 Form and Instruction 40
Proposal Cover Page Modified 130 130 0 Form and Instruction 41
QIF Evaluative Measures Report Modified 50 75 0 Form and Instruction 42
QIF Progress Report Modified 300 450 0 Form and Instruction 43
QIF Project Plan Form Modified 100 100 0 Form and Instruction 46
QIF TJI Evaluative Measures Report New 540 810 0 Form and Instruction 44
QIF TJI Progress Report New 540 810 0 Form and Instruction 45
Summary Page (New Access Point) Modified 500 500 0 Form and Instruction 47
Summary Page (Service Area Competition) New 360 180 0 Form and Instruction 48
Total burden requested under this ICR: 30350 32789 0  
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