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:
201007-0915-001
Status:
Historical Active
Previous ICR Reference No:
200706-0915-005
Agency/Subagency:
HHS/HSA
Agency Tracking No:
Title:
The Health Center Program Application Forms
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
10/04/2010
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/01/2010
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
10/31/2013
36 Months From Approved
10/31/2010
Responses
22,758
0
15,131
Time Burden (Hours)
37,139
0
52,688
Cost Burden (Dollars)
0
0
0
Abstract:
This ICR contains revisions to 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:
75 FR 15436
03/29/2010
30-day Notice:
Federal Register Citation:
Citation Date:
75 FR 33310
06/11/2010
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
31
IC Title
Form No.
Form Name
The Health Center Program Application Forms
0285-3
Income Analysis Form
The Health Center Program Application Forms
0285-Delete Services
CIS_Delete Services Checklist
The Health Center Program Application Forms
0285-4
Documents on File
The Health Center Program Application Forms
0285-2
Staffing Profile
The Health Center Program Application Forms
0285-4
Community Characteristics
The Health Center Program Application Forms
0285-5a
Services Provided
The Health Center Program Application Forms
0285-5b
Service Sites Listing
The Health Center Program Application Forms
0285- HC Plan- BPR
Health Care Plan- Non Competing
The Health Center Program Application Forms
0285-5c
Other Activities
The Health Center Program Application Forms
0285-6a
Board Member Characteristics
The Health Center Program Application Forms
0285-6b
Request for Waiver of Governance Requirements
The Health Center Program Application Forms
0285-8
Health Center Affiliation Certification
The Health Center Program Application Forms
0285-9
Need for Assistance
The Health Center Program Application Forms
0285-10
Annual Emergency Preparedness
The Health Center Program Application Forms
0285-HC Plan-SAC NAP
Health Care Plan- Competing
The Health Center Program Application Forms
0285-12
Points of Contact
The Health Center Program Application Forms
0285-Business Plan-SAC NAP
Business Plan- SAC NAP
The Health Center Program Application Forms
0285-Business Plan-BPR
Business Plan- Non Competing
The Health Center Program Application Forms
0285-Add Site Checklist
CIS Add Site Checklist
The Health Center Program Application Forms
0285-1a
General Info Worksheet
The Health Center Program Application Forms
0285-1a
Planning Grant-General Info Worksheet
The Health Center Program Application Forms
0285-Proposal Cover Pg
Capital Improvement_Investment Proposal Cover Page
The Health Center Program Application Forms
0285-Project Cover
Capital Improvement_Investment Project Cover
The Health Center Program Application Forms
0285-Project Impact
Capital Improvement_Investment Project Impact
The Health Center Program Application Forms
0285- Assurances
Assurances
The Health Center Program Application Forms
0285-Equipment list
Equipment List
The Health Center Program Application Forms
0285-Other Reqs
Other Requirements for Sites
The Health Center Program Application Forms
0285-Delete Site Checklist
CIS Delete Site Checklist
The Health Center Program Application Forms
0285-Relocate Site
CIS-Relocation Site Checklist
The Health Center Program Application Forms
0285-Add Services
CIS_Add Services Checklist
The Health Center Program Application Forms
0285-1b
Funding Request Summary
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
22,758
15,131
0
7,547
80
0
Annual Time Burden (Hours)
37,139
52,688
0
13,775
-29,324
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
The total annual burden for this activity has decreased by 15,549 hours while the total responses have increased by 7,627 from the last approval. The decrease of 29,324 hours is due to program adjustments resulting from streamlining application forms, electronic structuring of forms and re-assessing the previous burden hours since the last approval. There has been a program change increase in burden hours by 13,775 hours and 7,547 responses as a result of newly added application forms. The net total annual burden for this activity is 37,139 hours.
Annual Cost to Federal Government:
$138,000
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]?
No
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)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Susan Queen 3014431129
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:
07/01/2010
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