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:
201608-0915-003
Status:
Historical Active
Previous ICR Reference No:
201410-0915-001
Agency/Subagency:
HHS/HSA
Agency Tracking No:
21063
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 with change
Conclusion Date:
01/30/2017
Retrieve Notice of Action (NOA)
Date Received in OIRA:
08/16/2016
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2020
36 Months From Approved
01/31/2017
Responses
35,566
0
32,450
Time Burden (Hours)
44,608
0
44,825
Cost Burden (Dollars)
0
0
0
Abstract:
Health Center Program-specific forms provide information essential for application evaluation, funding and designation recommendation and approval, monitoring, and ensuring compliance with Health Center Program legislative and regulatory requirements. The forms are/will be used by existing health centers and other organizations to apply for grant and non-grant opportunities, renew grant or non-grant designation, and change scope of project.
Authorizing Statute(s):
US Code:
42 USC 254b Section 330
Name of Law: Health Centers, Public Health Service Act, as amended
Citations for New Statutory Requirements:
US Code: 42 USC 300, Section 1006[c] Name of Law: Public Health Service Act
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:
81 FR 41
03/02/2016
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 156
08/12/2016
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
41
IC Title
Form No.
Form Name
Annual Emergency Preparedness Report
10, 10
Emergency Preparedness Report
,
Emergency Preparedness Report Final
Checklist for Adding New Service
31, 31
Checklist for Adding New Service - track changes
,
Checklist for Adding New Service 2017 Final
Checklist for Adding a New Target Population
33
Checklist for Adding a New Target Population - track changes
Checklist for Adding a new Service Delivery Site
29, 29
Checklist for Adding a New Service Delivery Site - track changes
,
Checklist for Adding a New Service Delivery Site 2017 Final
Checklist for Deleting Existing Service
32, 32
Checklist for Deleting Existing Service - track changes.docx
,
Checklist for Deleting Existing Service 2017 Final
Checklist for Deleting Existing Service Delivery Site
30, 30
Checklist for Deleting Existing Service Delivery Site - track changes
,
Checklist for Deleting Existing Service Delivery Site 2017 Final
Checklist for Replacing Existing Service Delivery Site
1
Checklist for replacing existing service delivery site
Clinical Performance Measures
17, 17
Clinical Performance Measures (track changes)
,
Clinical Performance Measures Final
Community Characteristics
4, 4
Community Characteristics
,
Community Characteristics Final
Current Board Member Characteristics
6A, 6A
Current Board Member Characteristics
,
Current Board Member Characteristics Final
Documents on File
1C
Documents on File
EHR Readiness Checklist
1
EHR Readiness Checklist
Equipment List
23, 23
Equipment List (track changes)
,
Equipment List Final
Expanded Services
34, 34
Expanded Services
,
Increased Demand for Services (track changes)
Federal Object Class Categories
35, 35
Federal Object Class Categories 2017
,
Supplemental Line_Item_Budget (track changes).docx
Financial Performance Measures
18
Financial Performance Measures (track changes)
Funding Request Summary
1B, 1B
BPHC Funding Request Summary
,
BPHC Funding Request Summary Final
Funding Sources
25, 25
Funding Sources (track changes)
,
Funding Sources 2017 Final
General Information Worksheet
1A
General Information Worksheet
Health Center Agreements
8, 8
Health Center Agreements
,
Health Center Agreements Final
Health Center Controlled Networks Progress Report
40, 40
HCCN Progress Report (track changes)
,
HCCN Progress Report Final
Health Center Controlled Networks Work Plan
41, 41
HCCN Work Plan (track changes)
,
HCCN Work Plan 2016 Cohort.pdf
Implementation Plan
19, 19
Implementation Plan (track changes)
,
Implementation plan 2017 Final
Income Analysis
3, 3, 3A, 3A
Income Analysis
,
Income Analysis Final
,
Look alike Budget
,
Look Alike Budget Information Final
Look Alike Budget
1
Look Alike Budget
Need for Assitance Worksheet
9, 9
Need for Assistance Worksheet
,
Need for Assistance Worksheet Final
O & E Progress Report
28, 28
OE Progress_Report (track changes)
,
OE Progress_Report 2017 Final
O & E Supplemental
27, 27
Outreach and Enrollment Supplemental form (track changes).docx
,
Outreach and Enrollment Supplemental 2017 Final
Organization Contacts
12, 12
Organization Contacts
,
Organization Contacts Final
Other Activities/Locations
5C, 5C
Other Activities/Locations
,
Other Activities/Locations Final
Other Requirements for Sites
24, 24
Other requirement for sites (track changes)
,
Other requirement for sites 2017 Final
Program Narrative Update
38
Program Narrative Update 2017
Project Cover Page
22
Project Cover Page (track changes)
Project Qualification Criteria
26, 26
Project Qualification Criteria (track changes)
,
Project Qualification Criteria 2017 Final
Project Work Plan
20, 20
Project Work Plan (track changes)
,
Project Work Plan Final
Proposal Cover Page
21, 21
Proposal Cover Page (track changes)
,
Proposal Cover Page 2017 Final
Request for Waiver of Governance Requirements
6B, 6B
Request for Waiver of Board Member
,
Request for Waiver of Board Member Final
Service Sites
5B
Service Sites
Services Provided
5A, 5A
Services Provided
,
Services Provided Final
Staffing Profile
2, 2
Staffing Profile
,
Staffing Profile Final
Substance Abuse Progress Report
39
Substance Abuse Progress Report
Summary Page
37
Summary Page 2017.docx
Supplemental Information
36
Supplemental 2017.docx
Verification Checklist
1
Verification Checklist
Zika Progress Report
42
Zika Progress Report.pdf
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
35,566
32,450
0
4,166
-1,050
0
Annual Time Burden (Hours)
44,608
44,825
0
1,408
-1,625
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:
Yes
Burden Reduction Due to:
Using Information Technology
Short Statement:
The use of information technology has reduced the burden in some forms used in this ICR. Burden increases are due to more information needed from respondents.
Annual Cost to Federal Government:
$171,586
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:
Elyana Bowman 301 443-3983 enadjem@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:
08/16/2016
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