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:
201312-0915-005
Status:
Historical Active
Previous ICR Reference No:
201307-0915-005
Agency/Subagency:
HHS/HSA
Agency Tracking No:
21063
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:
01/02/2014
Retrieve Notice of Action (NOA)
Date Received in OIRA:
12/20/2013
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
09/30/2016
09/30/2016
09/30/2016
Responses
32,640
0
32,450
Time Burden (Hours)
45,015
0
44,825
Cost Burden (Dollars)
0
0
0
Abstract:
Health Center Program forms are critical to the Program grant and non-grant award process, as well as to Program oversight and monitoring activities. These forms are used by health centers to request funding under Section 330 of the Public Health Service (PHS) Act, change their scope of project and become designated as Look-Alikes. Over 1,200 health centers deliver comprehensive, high quality, cost-effective primary health care to America's most vulnerable populations.
Authorizing Statute(s):
PL:
Pub.L. 107 - 251 101
Name of Law: Health Centers
US Code:
42 USC 254b
Name of Law: Health Centers
PL:
Pub.L. 111 - 148 5601
Name of Law: Patient Protection and Affordable Care Act of 2010
PL:
Pub.L. 111 - 148 10503
Name of Law: Patient Protection and Affordable Care Act of 2010
PL:
Pub.L. 111 - 152 2303
Name of Law: Health Care and Educational Reconciliation Act of 2010
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:
38
IC Title
Form No.
Form Name
Annual Emergency Preparedness Report
10
Annual Emergency Preparedness Report
Checklist for Adding New Service
1
Checklist for adding new service
Checklist for Adding a New Target Population
1
checklist for adding a new target population
Checklist for Adding a new Service Delivery Site
1
Checklist for Adding a New Service Delivery Site
Checklist for Deleting Existing Service
1
Checklist for deleting existing service
Checklist for Deleting Existing Service Delivery Site
1
Checklist for Deleting Existing Service Delivery Site
Checklist for Replacing Existing Service Delivery Site
1
Checklist for replacing existing service delivery site
Clinical Performance Measures
1
Clinical Performance Measures
Community Characteristics
4
Community Characteristics
Current Board Member Characteristics
6a
Current Board Member Characteristics
Documents on File
1C
Documents on File
EHR Readiness Checklist
1
EHR Readiness Checklist
Equipment List
1
Equipment List
Financial Performance Measures
1
Financial Performance Measures
Funding Request Summary
1B
Funding Request Summary
Funding Sources
1
Funding Sources
General Information Worksheet
1
General Information Worksheet
Health Center Agreements
8
Health Center Agreements
Implementation Plan
1
Implementation Plan
Income Analysis
3
Income Analysis
Increased Demand for Services
1
Increased demand for services
Look Alike Budget
1
Look Alike Budget
Need for Assitance Worksheet
9
Need for Assistance Worksheet
Oamp;E Progress Report
1
O&E Progress Report
Oamp;E Supplemental
1
O&E Supplemental
Organization Contacts
12
Organization Contacts
Other Activities/Locations
5c
other activities/locations
Other Requirements for Sites
1
Other Requirements for Sites
Project Cover Page
1
Project Cover Page
Project Qualification Criteria
1
Project Qualification Criteria
Project Work Plan
1
Project Work Plan
Proposal Cover Page
1
Proposal Cover Page
Request for Waiver of Governance Requirements
6b
Request for waiver of governance requirements
Service Sites
5b
Service Sites
Services Provided
5a
Services Provided
Staffing Profile
2
Staffing Profile
Supplemental Line Item Budget
1
Supplemental Line Item Budget
Verification Checklist
1
Verification Checklist
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
32,640
32,450
0
190
0
0
Annual Time Burden (Hours)
45,015
44,825
0
190
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]?
Yes
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:
Jodi Duckhorn 301 443-1984
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:
12/20/2013
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