View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0915-0285
ICR Reference No:
200706-0915-005
Status:
Historical Active
Previous ICR Reference No:
200402-0915-001
Agency/Subagency:
HHS/HSA
Agency Tracking No:
Title:
The Health Center Program Application Forms
Type of Information Collection:
Extension without change of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
08/23/2007
Retrieve Notice of Action (NOA)
Date Received in OIRA:
06/20/2007
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
08/31/2010
36 Months From Approved
08/31/2007
Responses
15,131
0
1,425
Time Burden (Hours)
52,688
0
59,375
Cost Burden (Dollars)
0
0
0
Abstract:
This ICR contains forms that are used by Health Centers to request support for several programs under Section 330 of the Public Health Service Act. These forms provide HRSA with information that is required in order to make appropriate funding decisions. The Health Centers apply for one or more of the listed funding opportunities based on their eligibility.
Authorizing Statute(s):
US Code:
42 USC 254b
Name of Law: Health Centers
PL:
Pub.L. 107 - 251 101
Name of Law: Health Centers
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
72 FR 15889
04/03/2007
30-day Notice:
Federal Register Citation:
Citation Date:
72 FR 32124
06/11/2007
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
18
IC Title
Form No.
Form Name
The Health Center Program Application Forms
0285 income analysis
0285 income analysis
The Health Center Program Application Forms
0285 planning
0285 planning worksheet
The Health Center Program Application Forms
0285 services provided
0285 services provided
The Health Center Program Application Forms
0285 sites
0285 sites
The Health Center Program Application Forms
0285 waiver
0285 waiver
The Health Center Program Application Forms
0285 compliance
0285 compliance
The Health Center Program Application Forms
0285 certification
0285 certification
The Health Center Program Application Forms
0285 other site activities
0285 other site activities
The Health Center Program Application Forms
0285 affiliation checklist
0285 hc affiliation checklist
The Health Center Program Application Forms
0285 need for assistance
0285 need for assistance
The Health Center Program Application Forms
0285 emergency preparedness
0285 emergency preparedness
The Health Center Program Application Forms
0285 ftca form
0285 ftca form
The Health Center Program Application Forms
0285 contact information
0285 contact information
The Health Center Program Application Forms
0285 1
0285 general information worksheet
The Health Center Program Application Forms
0285 staff profile
0285 staff profile
The Health Center Program Application Forms
0285 Board members
0285 Board members
The Health Center Program Application Forms
0285 funding
0285 funding summary
The Health Center Program Application Forms
0285 community characteristics
0285 community characteristics
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
15,131
1,425
0
0
13,706
0
Annual Time Burden (Hours)
52,688
59,375
0
0
-6,687
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$59,800
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Uncollected
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Saleda Perryman
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
06/20/2007
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