The Health Center Program Application Forms

Forms and Documents

Document Name	Status
Form 0285 1 The Health Center Program Application Forms Form	Modified
Form 0285 contact infor The Health Center Program Application Forms Form	New
Form 0285 ftca form The Health Center Program Application Forms Form	New
Form 0285 emergency pre The Health Center Program Application Forms Form	New
Form 0285 need for assi The Health Center Program Application Forms Form	New
Form 0285 certification The Health Center Program Application Forms Form	New
Form 0285 compliance The Health Center Program Application Forms Form	New
Form 0285 waiver The Health Center Program Application Forms Form	New
Form 0285 Board members The Health Center Program Application Forms Form	New
Form 0285 other site ac The Health Center Program Application Forms Form	New
Form 0285 sites The Health Center Program Application Forms Form	New
Form 0285 services prov The Health Center Program Application Forms Form	New
Form 0285 community cha The Health Center Program Application Forms Form	New
Form 0285 income analys The Health Center Program Application Forms Form	New
Form 0285 staff profile The Health Center Program Application Forms Form	New
Form 0285 affiliation c The Health Center Program Application Forms Form	New
Form 0285 funding The Health Center Program Application Forms Form	New
Form 0285 planning The Health Center Program Application Forms Form	New
ss 0285 07.doc Supporting Statement A	2007-06-15

IC Document Collections

IC ID	Document Title	Status
6538	The Health Center Program Application Forms Form	Modified
180786	The Health Center Program Application Forms Form	New
180785	The Health Center Program Application Forms Form	New
180784	The Health Center Program Application Forms Form	New
180783	The Health Center Program Application Forms Form	New
180782	The Health Center Program Application Forms Form	New
180781	The Health Center Program Application Forms Form	New
180780	The Health Center Program Application Forms Form	New
180779	The Health Center Program Application Forms Form	New
180778	The Health Center Program Application Forms Form	New
180777	The Health Center Program Application Forms Form	New
180776	The Health Center Program Application Forms Form	New
180775	The Health Center Program Application Forms Form	New
180774	The Health Center Program Application Forms Form	New
180773	The Health Center Program Application Forms Form	New
180772	The Health Center Program Application Forms Form	New
180771	The Health Center Program Application Forms Form	New
180770	The Health Center Program Application Forms Form	New

ICR Details

OMB Control No: 0915-0285	ICR Reference No: 200706-0915-005
Status: Historical Active	Previous ICR Reference No: 200402-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: The Health Center Program Application Forms
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/23/2007
	Date Received in OIRA: 06/20/2007
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	36 Months From Approved	08/31/2007
Responses	15,131	0	1,425
Time Burden (Hours)	52,688	0	59,375
Cost Burden (Dollars)	0	0	0

---

Abstract: This ICR contains forms that are used by Health Centers to request support for several programs under Section 330 of the Public Health Service Act. These forms provide HRSA with information that is required in order to make appropriate funding decisions. The Health Centers apply for one or more of the listed funding opportunities based on their eligibility.

---

Authorizing Statute(s): US Code: 42 USC 254b Name of Law: Health Centers
   PL: Pub.L. 107 - 251 101 Name of Law: Health Centers
  

Citations for New Statutory Requirements: None

---

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:
	72 FR 15889	04/03/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 32124	06/11/2007
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 18

IC Title	Form No.	Form Name
The Health Center Program Application Forms	0285 income analysis	0285 income analysis
The Health Center Program Application Forms	0285 community characteristics	0285 community characteristics
The Health Center Program Application Forms	0285 services provided	0285 services provided
The Health Center Program Application Forms	0285 sites	0285 sites
The Health Center Program Application Forms	0285 waiver	0285 waiver
The Health Center Program Application Forms	0285 compliance	0285 compliance
The Health Center Program Application Forms	0285 certification	0285 certification
The Health Center Program Application Forms	0285 other site activities	0285 other site activities
The Health Center Program Application Forms	0285 Board members	0285 Board members
The Health Center Program Application Forms	0285 affiliation checklist	0285 hc affiliation checklist
The Health Center Program Application Forms	0285 need for assistance	0285 need for assistance
The Health Center Program Application Forms	0285 emergency preparedness	0285 emergency preparedness
The Health Center Program Application Forms	0285 ftca form	0285 ftca form
The Health Center Program Application Forms	0285 contact information	0285 contact information
The Health Center Program Application Forms	0285 1	0285 general information worksheet
The Health Center Program Application Forms	0285 funding	0285 funding summary
The Health Center Program Application Forms	0285 planning	0285 planning worksheet
The Health Center Program Application Forms	0285 staff profile	0285 staff profile

---

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	15,131	1,425	0	0	13,706	0
Annual Time Burden (Hours)	52,688	59,375	0	0	-6,687	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $59,800

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

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: 06/20/2007

---