Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
2026 Grant Number Form Modified 400 100 0 Form and Instruction 23
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 Modified 50 50 0 Form and Instruction 50
Checklist for Adding a Service Site to Scope Modified 1250 1875 0 Form and Instruction 3
Checklist for Adding a Service to Scope Modified 450 450 0 Form and Instruction 2
Checklist for Deleting a Service Site from Scope Modified 500 500 0 Form and Instruction 5
Checklist for Deleting a Service from Scope Modified 500 500 0 Form and Instruction 4
Checklist for Form 5A Scope Adjustments Modified 1000 1000 0 Form and Instruction 51
Checklist for Form 5B Scope Adjustments Modified 2000 2000 0 Form and Instruction 52
Checklist for Replacing a Service Site in Scope: New 250 188 0 Form and Instruction 53
Equipment List Modified 130 65 0 Form and Instruction 6
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 5A: Services Provided Modified 1400 350 0 Form and Instruction 14
Form 5B: Sites Modified 1400 350 0 Form and Instruction 15
Form 5C: Other Activities/Locations Removed 0 0 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 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 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 Modified 110 55 0 Form and Instruction 49
Loan Guarantee Financial Performance Indicators Modified 5 5 0 Form and Instruction 8
Loan Guarantee Progress Report: New 88 88 0 Form and Instruction 54
NH-NCC Project Work Plan Update Modified 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 Modified 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
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 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 Modified 540 810 0 Form and Instruction 44
QIF TJI Progress Report Modified 540 810 0 Form and Instruction 45
Quality Improvement Fund (QIF) Final Report New 25 75 0 Form and Instruction 55
Summary Page (New Access Point) Modified 500 500 0 Form and Instruction 47
Summary Page (Service Area Competition) Modified 360 180 0 Form and Instruction 48
Total burden requested under this ICR: 29057 31167 0  
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