View Information Collection Request (ICR) Package

View ICR - Agency Submission

OMB Control No: 0915-0285	ICR Reference No: 202610-0915-001
Status: Received in OIRA	Previous ICR Reference No: 202603-0915-004
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	Date Submitted to OIRA: 10/21/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2029
Responses	29,057	30,350
Time Burden (Hours)	31,167	32,789
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion	Change Due to Adjustment in Estimate
Annual Number of Responses	29,057	30,350	-743	-550
Annual Time Burden (Hours)	31,167	32,789	-1,484	-138
Annual Cost Burden (Dollars)	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: Changing Forms

Short Statement: This revision updates eight currently approved forms and adds three new forms. The revisions streamline and clarify existing data collection requirements and are expected to reduce respondent burden. The three new forms add 350.5 annual burden hours; however, these hours are more than offset by burden reductions associated with the revised forms and the exclusion of Form 5C: Other Activities/Locations. Form 5C accounts for 550 annual responses and 137.5 annual burden hours and had been discontinued by the program during the earlier 2026 package revision but was inadvertently retained in the published 60-day Federal Register Notice burden table. Overall, the unrounded annual burden decreases from 32,785.55 hours to 31,164.55 hours, a net reduction of 1,621 hours.

Annual Cost to Federal Government: $293,938

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? No

Agency Contact: Laura Cooper 301 443-2126 lcooper@hrsa.gov

Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.