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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:
202301-0915-005
Status:
Active
Previous ICR Reference No:
202011-0915-002
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 without change
Conclusion Date:
04/21/2023
Retrieve Notice of Action (NOA)
Date Received in OIRA:
02/08/2023
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
04/30/2026
36 Months From Approved
04/30/2023
Responses
39,279
0
48,063
Time Burden (Hours)
46,529
0
59,242
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:
87 FR 62861
10/17/2022
30-day Notice:
Federal Register Citation:
Citation Date:
88 FR 6284
01/31/2023
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
52
IC Title
Form No.
Form Name
Applicant Qualification Criteria Form
13
Applicant Qualification Criteria Form
Capital Semi Annual Progress Report
9a
Capital Semi Annual Progress Report
Capital Semi-Annual Progress Report
1, 2
Capital Semi Annual Progress Report (SAPR).docx
,
Progress Report COVID Mark Up_5.26.20.pdf
Checklist for Adding New Service
2, 2E
Checklist for Adding New Service -Clean.docx
,
Checklist for Adding New Service edits.docx
Checklist for Adding a New Target Population
4, 4E
Checklist for Adding a New Target Population - Clean.docx
,
Checklist for Adding a New Target Population edits.docx
Checklist for Adding a new Service Delivery Site
3, 3E
Checklist for Adding a New Service Delivery Site - Clean.docx
,
Checklist for Adding a New Service Delivery Site edits.docx
Checklist for Deleting Existing Service
5, 5E
Checklist for Deleting Existing Service -Clean.docx
,
Checklist for Deleting Existing Service - edits.docx
Checklist for Deleting Existing Service Delivery Site
6E, 6
Checklist for Deleting Existing Service Delivery Site - Clean.docx
,
Checklist for Deleting Existing Service Delivery Site edits.docx
Clinical Performance Measures
7, 7E
Clinical Performance Measures Clean.docx
,
Clinical Performance Measures edits.docx
Diabetes Action Plan - Quarterly Report Template
8
Diabetes Action Plan Quarterly Report.docx
Equipment List
9
Equipment List
Expanded Services
10, 10E
Expanded Services Clean.docx
,
Expanded Services - edits.docx
FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting
28
FY2018 Expanding Access to Quality SUD-MH IBHS Progress Reporting.docx
FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting
29, 29
FY2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting.docx
,
Progress Report PCHP Mark Up_add new report 10.30.20.docx
FY 2022 Accelerating Cancer Screening Progress Report
13
FY 2022 Accelerating Cancer Screening Progress Report
Federal Object Class Categories
11
Federal Object Class Category Form- clean.docx
Financial Performance Indicators
12, 12E
Financial Performance Measures - clean.docx
,
Financial Performance Measures - edits.docx
Form 12: Organization Contacts
26, 26E
Form 12 - Clean.docx
,
Form 12 - edits.docx
Form 1A: General Information Worksheet
13E, 13
Form 1A - clean.docx
,
Form 1A - edits.docx
Form 1B: BPHC Funding Request Summary
14, 14E
Form 1B - clean.docx
,
Form 1B - edits.DOCX
Form 1C: Documents on File
15, 15E
Form 1C - clean.docx
,
Form 1C edits.docx
Form 2: Staffing Profile
16, 16E
Form 2 - clean.docx
,
Form 2 - edits.docx
Form 3: Income Analysis
17E, 17
Form 3 - edits.docx
,
Form 3 - clean.docx
Form 3A: FQHC Look-Alike Budget Information
18, 18E
Form 3A - clean.docx
,
Form 3A - edits.docx
Form 4: Community Characteristics
19, 19E
Form 4 - Clean.docx
,
Form 4 - edits.docx
Form 5A: Services Provided
20, 20E
Form 5A - clean.docx
,
Form 5A - edits.docx
Form 5B: Service Sites
21, 21E
Form 5B - clean.docx
,
Form 5B - edits.docx
Form 5C: Other Activities/Locations
22E, 22
Form 5C - Clean.docx
,
Form 5C - edits.docx
Form 6A: Current Board Member Characteristics
23, 23E
Form 6A - Clean.docx
,
Form 6A - edits.docx
Form 6B: Request for Waiver of Governance Requirements
24, 24E
Form 6B - Clean.docx
,
Form 6B - edits.docx
Form 8: Health Center Agreements
25, 25E
Form 8 - Clean.docx
,
Form 8 - edits.docx
Funding Request Summary Form (SBHC)
15
Funding Request Summary Form
Funding Sources
27
Funding Sources - clean.docx
HRSA EHBs Action Plan
33
HRSA EHBs Action Plan.docx
HRSA Loan Guarantee Program Application
34
HRSA Loan Guarantee Program Application.docx
Health Center Controlled Networks (HCCN) Progress Report Table
10a
HCCN Progress Report
Health Center Program Progress Report
31, 31E
Health Center Program Progress Report - Clean.docx
,
Health Center Program Progress Report - edits.docx
Health Center Program: Supplemental Information
32, 32E
Health Center Program Supplemental Information - Clean.docx
,
Health Center Program Supplemental Information - Clean.docx
NHHCIA NCC Clinical Performance Measures
3a
NHHCIA NCC Clinical Performance Measures
NHHCIA NCC Financial Performance Measures
4a
NHHCIA NCC Financial Performance Measures
NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update
6b, 6c, 6a
NHHCIA NCC Income Analysis Form
,
NHHCIA NCC Project Work Plan Progress Report
,
NHHCIA NCC Project Work Plan Update
Operational Plan
35, 35E
Operational Plan - clean.docx
,
Operational Plan - edits.docx
Other Requirements for Sites
36
Other Requirements for Sites
Participating Health Center List
37
Participating Health Centers List.docx
Patient Impact Form
7a
Patient Impact Form
Patient Target and Calculations
38
Patient Target and Calculation.docx
Program Specific Forms Instructions
39, 39E
Program Specific Form Instructions Clean.docx
,
Program Specific Form Instructions Edits.docx
Progress Report Non-Capital Investment
7a
Progress Report- Non-Capital Investments
Project Cover Page
12
Proposal Cover Page
Project Narrative Update
40, 40E
Project Narrative Update - clean.docx
,
Project Narrative Update - edits.docx
Project Overview
41
Project Overview.docx
Project Plan
42
Project Plan.docx
Project Qualification Criteria
43
Project Qualification Criteria.docx
Project Work Plan
44, 44E
Project Work Plan - clean.docx
,
Project Work Plan - edits.docx
Proposal Cover Page
45
Proposal Cover Page.docx
QIF Evaluative Measures Report
11
QIF Evaluative Measures Report
QIF Progress Report
1a
QIF Progress Report
QIF Project Plan Form
2a
QIF Project Plan Form
Summary Page
46, 46E
Summary Page - clean.docx
,
Summary Page - edits.docx
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
39,279
48,063
0
8,855
-17,639
0
Annual Time Burden (Hours)
46,529
59,242
0
11,803
-24,516
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:
Miscellaneous Actions
Short Statement:
The decrease in hours is due to the number of applicants that will be asked to leverage these forms. Additionally, the data needed for new funding opportunities could be captured in forms previously approved.
Annual Cost to Federal Government:
$154,046
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
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?
Yes
Agency Contact:
Tierra Moore 301 443-0496 tmoore@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:
02/08/2023