View Information Collection Request (ICR) Package
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Brief and OIRA conclusion
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IC List
Burden
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Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
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:
201010-0915-006
Status:
Historical Active
Previous ICR Reference No:
201007-0915-001
Agency/Subagency:
HHS/HSA
Agency Tracking No:
Title:
The Health Center Program Application Forms
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
12/14/2010
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/29/2010
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
10/31/2013
10/31/2013
10/31/2013
Responses
22,758
0
22,758
Time Burden (Hours)
37,139
0
37,139
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):
PL:
Pub.L. 107 - 251 101
Name of Law: Health Centers
US Code:
42 USC 254b
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
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
0285-12
Points of Contact
The Health Center Program Application Forms
0285- Assurances
Assurances
The Health Center Program Application Forms
0285-1a
Planning Grant-General Info Worksheet
The Health Center Program Application Forms
0285-1b
Funding Request Summary
The Health Center Program Application Forms
0285-HC Plan-SAC NAP
Health Care Plan- Competing
The Health Center Program Application Forms
0285-Business Plan-SAC NAP
Business Plan- SAC NAP
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-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-Delete Site Checklist
CIS Delete Site Checklist
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
0285-3
Income Analysis Form
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
0285-6b
Request for Waiver of Governance Requirements
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
0285-5b
Service Sites Listing
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- HC Plan- BPR
Health Care Plan- Non Competing
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-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
0285-1a
General Info Worksheet
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
22,758
0
0
0
0
Annual Time Burden (Hours)
37,139
37,139
0
0
0
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:
$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]?
No
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:
Gerta Bardhoshi 301 443-1129 GBardhoshi@hrsa.gov
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:
10/29/2010
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