The Health Center Program Application Forms

ICR 202301-0915-005

OMB: 0915-0285

Federal Form Document

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0915-0285 can be found here:

2025-05-21 - No material or nonsubstantive change to a currently approved collection
2024-11-26 - No material or nonsubstantive change to a currently approved collection

Forms and Documents

Document Name	Status
Form 1 Capital Semi-Annual Progress Report Form and Instruction	Removed
Form 15 Funding Request Summary Form (SBHC) Form and Instruction	New
Form 13 Applicant Qualification Criteria Form Form and Instruction	New
Form 9a Capital Semi Annual Progress Report Form and Instruction	New
Form 13 FY 2022 Accelerating Cancer Screening Progress Report Form and Instruction	New
Form 11 QIF Evaluative Measures Report Form and Instruction	New
Form 12 Project Cover Page Form and Instruction	New
Form 7a Progress Report Non-Capital Investment Form and Instruction	New
Form 7a Patient Impact Form Form and Instruction	New
Form 6a NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update Form and Instruction	New
Form 4a NHHCIA NCC Financial Performance Measures Form and Instruction	New
Form 3a NHHCIA NCC Clinical Performance Measures Form and Instruction	New
Form 2a QIF Project Plan Form Form and Instruction	New
Form 1a QIF Progress Report Form and Instruction	New
Form 39 Program Specific Forms Instructions Form and Instruction	Removed
Form 38 Patient Target and Calculations Form and Instruction	Unchanged
Form 37 Participating Health Center List Form and Instruction	Unchanged
Form 18 Form 3A: FQHC Look-Alike Budget Information Form and Instruction	Unchanged
Form 13 Form 1A: General Information Worksheet Form and Instruction	Unchanged
Form 8 Diabetes Action Plan - Quarterly Report Template Form and Instruction	Removed
Form 34 HRSA Loan Guarantee Program Application Form and Instruction	Unchanged
Form 10a Health Center Controlled Networks (HCCN) Progress Report Table Form and Instruction	Modified
Form 31 Health Center Program Progress Report Form and Instruction	Unchanged
Form 40 Project Narrative Update Form and Instruction	Modified
Form 46 Summary Page Form and Instruction	Modified
Form 11 Federal Object Class Categories Form and Instruction	Unchanged
Form 29 FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Form and Instruction	Unchanged
Form 28 FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting Form and Instruction	Removed
Form 32 Health Center Program: Supplemental Information Form and Instruction	Removed
Form 44 Project Work Plan Form and Instruction	Unchanged
Form 35 Operational Plan Form and Instruction	Unchanged
Form 43 Project Qualification Criteria Form and Instruction	Modified
Form 27 Funding Sources Form and Instruction	Unchanged
Form 10 Expanded Services Form and Instruction	Unchanged
Form 4 Checklist for Adding a New Target Population Form and Instruction	Unchanged
Form 36 Other Requirements for Sites Form and Instruction	Unchanged
Form 9 Equipment List Form and Instruction	Modified
Form 41 Project Overview Form and Instruction	Modified
Form 45 Proposal Cover Page Form and Instruction	Unchanged
Form 6 Checklist for Deleting Existing Service Delivery Site Form and Instruction	Unchanged
Form 3 Checklist for Adding a new Service Delivery Site Form and Instruction	Unchanged
Form 5 Checklist for Deleting Existing Service Form and Instruction	Unchanged
Form 2 Checklist for Adding New Service Form and Instruction	Unchanged
Form 12 Financial Performance Indicators Form and Instruction	Modified
Form 26 Form 12: Organization Contacts Form and Instruction	Modified
Form 7 Clinical Performance Measures Form and Instruction	Removed
Form 33 HRSA EHBs Action Plan Form and Instruction	Removed
Form 42 Project Plan Form and Instruction	Modified
Form 25 Form 8: Health Center Agreements Form and Instruction	Modified
Form 24 Form 6B: Request for Waiver of Governance Requirements Form and Instruction	Unchanged
Form 23 Form 6A: Current Board Member Characteristics Form and Instruction	Modified
Form 22 Form 5C: Other Activities/Locations Form and Instruction	Modified
Form 21 Form 5B: Service Sites Form and Instruction	Modified
Form 20 Form 5A: Services Provided Form and Instruction	Modified
Form 19 Form 4: Community Characteristics Form and Instruction	Modified
Form 17E Form 3: Income Analysis Form and Instruction	Modified
Form 16 Form 2: Staffing Profile Form and Instruction	Modified
Form 15 Form 1C: Documents on File Form and Instruction	Modified
Form 14 Form 1B: BPHC Funding Request Summary Form and Instruction	Modified
FY23 Supporting Statement Final Edited.docx Supporting Statement A	2023-02-07

IC Document Collections

IC ID	Document Title	Status
6538	Capital Semi-Annual Progress Report Form and Instruction	Removed
258364	Funding Request Summary Form (SBHC) Form and Instruction	New
258356	Applicant Qualification Criteria Form Form and Instruction	New
258281	Capital Semi Annual Progress Report Form and Instruction	New
258277	FY 2022 Accelerating Cancer Screening Progress Report Form and Instruction	New
258276	QIF Evaluative Measures Report Form and Instruction	New
258275	Project Cover Page Form and Instruction	New
258274	Progress Report Non-Capital Investment Form and Instruction	New
258272	Patient Impact Form Form and Instruction	New
258270	NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update Form and Instruction	New
258269	NHHCIA NCC Financial Performance Measures Form and Instruction	New
258267	NHHCIA NCC Clinical Performance Measures Form and Instruction	New
258266	QIF Project Plan Form Form and Instruction	New
258265	QIF Progress Report Form and Instruction	New
239183	Program Specific Forms Instructions Form and Instruction	Removed
239182	Patient Target and Calculations Form and Instruction	Unchanged
239181	Participating Health Center List Form and Instruction	Unchanged
239173	Form 3A: FQHC Look-Alike Budget Information Form and Instruction	Unchanged
239164	Form 1A: General Information Worksheet Form and Instruction	Unchanged
223047	Diabetes Action Plan - Quarterly Report Template Form and Instruction	Removed
223046	HRSA Loan Guarantee Program Application Form and Instruction	Unchanged
223045	Health Center Controlled Networks (HCCN) Progress Report Table Form and Instruction	Modified
223043	Health Center Program Progress Report Form and Instruction	Unchanged
223042	Project Narrative Update Form and Instruction	Modified
223041	Summary Page Form and Instruction	Modified
223040	Federal Object Class Categories Form and Instruction	Unchanged
207854	FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Form and Instruction	Unchanged
207853	FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting Form and Instruction	Removed
207852	Health Center Program: Supplemental Information Form and Instruction	Removed
207848	Project Work Plan Form and Instruction	Unchanged
207847	Operational Plan Form and Instruction	Unchanged
207846	Project Qualification Criteria Form and Instruction	Modified
207845	Funding Sources Form and Instruction	Unchanged
207844	Expanded Services Form and Instruction	Unchanged
207843	Checklist for Adding a New Target Population Form and Instruction	Unchanged
193532	Other Requirements for Sites Form and Instruction	Unchanged
193531	Equipment List Form and Instruction	Modified
193528	Project Overview Form and Instruction	Modified
193527	Proposal Cover Page Form and Instruction	Unchanged
193526	Checklist for Deleting Existing Service Delivery Site Form and Instruction	Unchanged
193525	Checklist for Adding a new Service Delivery Site Form and Instruction	Unchanged
193523	Checklist for Deleting Existing Service Form and Instruction	Unchanged
193522	Checklist for Adding New Service Form and Instruction	Unchanged
193520	Financial Performance Indicators Form and Instruction	Modified
180786	Form 12: Organization Contacts Form and Instruction	Modified
180785	Clinical Performance Measures Form and Instruction	Removed
180784	HRSA EHBs Action Plan Form and Instruction	Removed
180783	Project Plan Form and Instruction	Modified
180781	Form 8: Health Center Agreements Form and Instruction	Modified
180780	Form 6B: Request for Waiver of Governance Requirements Form and Instruction	Unchanged
180779	Form 6A: Current Board Member Characteristics Form and Instruction	Modified
180778	Form 5C: Other Activities/Locations Form and Instruction	Modified
180777	Form 5B: Service Sites Form and Instruction	Modified
180776	Form 5A: Services Provided Form and Instruction	Modified
180775	Form 4: Community Characteristics Form and Instruction	Modified
180774	Form 3: Income Analysis Form and Instruction	Modified
180773	Form 2: Staffing Profile Form and Instruction	Modified
180772	Form 1C: Documents on File Form and Instruction	Modified
180771	Form 1B: BPHC Funding Request Summary Form and Instruction	Modified

ICR Details