The Health Center Program Application Forms

Forms and Documents

Document Name	Status
Form 1A General Information Worksheet Form	Modified
Form 42 Zika Progress Report Form and Instruction	New
Form 41 Health Center Controlled Networks Work Plan Form	New
Form 40 Health Center Controlled Networks Progress Report Form	New
Form 39 Substance Abuse Progress Report Form and Instruction	New
Form 38 Program Narrative Update Form and Instruction	New
Form 37 Summary Page Form	New
Form 35 Federal Object Class Categories Form and Instruction	New
Form 36 Supplemental Information Form and Instruction	Modified
Form 28 O & E Progress Report Form and Instruction	Modified
Form 27 O & E Supplemental Form and Instruction	Modified
Form 1 Look Alike Budget Form	Removed
Form 1 EHR Readiness Checklist Form	Removed
Form 1 Verification Checklist Form	Removed
Form 20 Project Work Plan Form and Instruction	Modified
Form 19 Implementation Plan Form	Modified
Form 26 Project Qualification Criteria Form and Instruction	Modified
Form 25 Funding Sources Form and Instruction	Modified
Form 34 Expanded Services Form and Instruction	Modified
Form 33 Checklist for Adding a New Target Population Form and Instruction	Modified
Form 24 Other Requirements for Sites Form and Instruction	Modified
Form 23 Equipment List Form and Instruction	Modified
Form 22 Project Cover Page Form and Instruction	Modified
Form 21 Proposal Cover Page Form and Instruction	Modified
Form 30 Checklist for Deleting Existing Service Delivery Site Form and Instruction	Modified
Form 29 Checklist for Adding a new Service Delivery Site Form and Instruction	Modified
Form 1 Checklist for Replacing Existing Service Delivery Site Form	Removed
Form 32 Checklist for Deleting Existing Service Form and Instruction	Modified
Form 31 Checklist for Adding New Service Form and Instruction	Modified
Form 18 Financial Performance Measures Form	Modified
Form 12 Organization Contacts Form	Modified
Form 17 Clinical Performance Measures Form	Modified
Form 10 Annual Emergency Preparedness Report Form	Modified
Form 9 Need for Assitance Worksheet Form	Modified
Form 8 Health Center Agreements Form and Instruction	Modified
Form 6B Request for Waiver of Governance Requirements Form and Instruction	Modified
Form 6A Current Board Member Characteristics Form	Modified
Form 5C Other Activities/Locations Form	Modified
Form 5B Service Sites Form	Modified
Form 5A Services Provided Form	Modified
Form 4 Community Characteristics Form	Modified
Form 3 Income Analysis Form	Modified
Form 2 Staffing Profile Form	Modified
Form 1C Documents on File Form	Modified
Form 1B Funding Request Summary Form	Modified
Performance Measures Instructions.docx Supplementary Document	2016-08-16
Implementation Plan Instructions.docx Supplementary Document	2016-08-16
Program Specific Forms Instructions.docx Supplementary Document	2016-08-16
FINAL0285Forms Supporting Statement PASSBACK CLEAN.docx Supporting Statement A	2017-01-17

IC Document Collections

IC ID	Document Title	Status
6538	General Information Worksheet Form	Modified
223047	Zika Progress Report Form and Instruction	New
223046	Health Center Controlled Networks Work Plan Form	New
223045	Health Center Controlled Networks Progress Report Form	New
223043	Substance Abuse Progress Report Form and Instruction	New
223042	Program Narrative Update Form and Instruction	New
223041	Summary Page Form	New
223040	Federal Object Class Categories Form and Instruction	New
207854	Supplemental Information Form and Instruction	Modified
207853	O & E Progress Report Form and Instruction	Modified
207852	O & E Supplemental Form and Instruction	Modified
207851	Look Alike Budget Form	Removed
207850	EHR Readiness Checklist Form	Removed
207849	Verification Checklist Form	Removed
207848	Project Work Plan Form and Instruction	Modified
207847	Implementation Plan Form	Modified
207846	Project Qualification Criteria Form and Instruction	Modified
207845	Funding Sources Form and Instruction	Modified
207844	Expanded Services Form and Instruction	Modified
207843	Checklist for Adding a New Target Population Form and Instruction	Modified
193532	Other Requirements for Sites Form and Instruction	Modified
193531	Equipment List Form and Instruction	Modified
193528	Project Cover Page Form and Instruction	Modified
193527	Proposal Cover Page Form and Instruction	Modified
193526	Checklist for Deleting Existing Service Delivery Site Form and Instruction	Modified
193525	Checklist for Adding a new Service Delivery Site Form and Instruction	Modified
193524	Checklist for Replacing Existing Service Delivery Site Form	Removed
193523	Checklist for Deleting Existing Service Form and Instruction	Modified
193522	Checklist for Adding New Service Form and Instruction	Modified
193520	Financial Performance Measures Form	Modified
180786	Organization Contacts Form	Modified
180785	Clinical Performance Measures Form	Modified
180784	Annual Emergency Preparedness Report Form	Modified
180783	Need for Assitance Worksheet Form	Modified
180781	Health Center Agreements Form and Instruction	Modified
180780	Request for Waiver of Governance Requirements Form and Instruction	Modified
180779	Current Board Member Characteristics Form	Modified
180778	Other Activities/Locations Form	Modified
180777	Service Sites Form	Modified
180776	Services Provided Form	Modified
180775	Community Characteristics Form	Modified
180774	Income Analysis Form	Modified
180773	Staffing Profile Form	Modified
180772	Documents on File Form	Modified
180771	Funding Request Summary Form	Modified

ICR Details

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
	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

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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.

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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

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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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

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Number of Information Collection (IC) in this ICR: 41

IC Title	Form No.	Form Name
Request for Waiver of Governance Requirements	6B, 6B	Request for Waiver of Board Member ,   Request for Waiver of Board Member Final
Health Center Agreements	8, 8	Health Center Agreements ,   Health Center Agreements Final
Need for Assitance Worksheet	9, 9	Need for Assistance Worksheet ,   Need for Assistance Worksheet Final
Annual Emergency Preparedness Report	10, 10	Emergency Preparedness Report ,   Emergency Preparedness Report Final
Checklist for Replacing Existing Service Delivery Site	1	Checklist for replacing existing service delivery site
EHR Readiness Checklist	1	EHR Readiness Checklist
Federal Object Class Categories	35, 35	Federal Object Class Categories 2017 ,   Supplemental Line_Item_Budget (track changes).docx
Verification Checklist	1	Verification Checklist
Summary Page	37	Summary Page 2017.docx
Funding Request Summary	1B, 1B	BPHC Funding Request Summary ,   BPHC Funding Request Summary Final
Documents on File	1C	Documents on File
Staffing Profile	2, 2	Staffing Profile ,   Staffing Profile Final
Income Analysis	3, 3, 3A, 3A	Income Analysis ,   Income Analysis Final ,   Look alike Budget ,   Look Alike Budget Information Final
Community Characteristics	4, 4	Community Characteristics ,   Community Characteristics Final
Services Provided	5A, 5A	Services Provided ,   Services Provided Final
Service Sites	5B	Service Sites
Other Activities/Locations	5C, 5C	Other Activities/Locations ,   Other Activities/Locations Final
Current Board Member Characteristics	6A, 6A	Current Board Member Characteristics ,   Current Board Member Characteristics Final
Program Narrative Update	38	Program Narrative Update 2017
Substance Abuse Progress Report	39	Substance Abuse Progress Report
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
Zika Progress Report	42	Zika Progress Report.pdf
Clinical Performance Measures	17, 17	Clinical Performance Measures (track changes) ,   Clinical Performance Measures Final
Organization Contacts	12, 12	Organization Contacts ,   Organization Contacts Final
Financial Performance Measures	18	Financial Performance Measures (track changes)
Checklist for Adding New Service	31, 31	Checklist for Adding New Service - track changes ,   Checklist for Adding New Service 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 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 Delivery Site	30, 30	Checklist for Deleting Existing Service Delivery Site - track changes ,   Checklist for Deleting Existing Service Delivery Site 2017 Final
Proposal Cover Page	21, 21	Proposal Cover Page (track changes) ,   Proposal Cover Page 2017 Final
Project Cover Page	22	Project Cover Page (track changes)
Equipment List	23, 23	Equipment List (track changes) ,   Equipment List Final
Other Requirements for Sites	24, 24	Other requirement for sites 2017 Final ,   Other requirement for sites (track changes)
Checklist for Adding a New Target Population	33	Checklist for Adding a New Target Population - track changes
Expanded Services	34, 34	Expanded Services ,   Increased Demand for Services (track changes)
Funding Sources	25, 25	Funding Sources (track changes) ,   Funding Sources 2017 Final
Project Qualification Criteria	26, 26	Project Qualification Criteria (track changes) ,   Project Qualification Criteria 2017 Final
Implementation Plan	19, 19	Implementation Plan (track changes) ,   Implementation plan 2017 Final
Project Work Plan	20, 20	Project Work Plan (track changes) ,   Project Work Plan Final
O & E Supplemental	27, 27	Outreach and Enrollment Supplemental form (track changes).docx ,   Outreach and Enrollment Supplemental 2017 Final
O & E Progress Report	28, 28	OE Progress_Report (track changes) ,   OE Progress_Report 2017 Final
Supplemental Information	36	Supplemental 2017.docx
General Information Worksheet	1A	General Information Worksheet
Look Alike Budget	1	Look Alike Budget

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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.

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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

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Common Form ICR:  No

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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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