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Supporting Statement

The Health Center Program Application Forms

A. JUSTIFICATION

1. Circumstances of Information Collection

The Health Resources and Services Administration (HRSA) is requesting an extension of OMB approval for forms that are used by several Bureau of Primary Health Care (BPHC) programs providing funding opportunities. These forms are used to request funding under Section 330 of the Public Health Service (PHS) Act or to apply for cost based reimbursement and drug pricing benefits for entities that do not receive 330 funding. The forms were approved under OMB number 0915-0285, the Presidential Initiative Application for Funding Opportunities, and the current expiration date is June 30, 2007. The forms approved in the last clearance request are part of the effort to expand health center access in the neediest communities. The initiative has provided health center support for new access points and for expanded medical capacity and services.

These forms are used by Health Centers to apply for funding under section 330 (as amended by Public Law 107-251): 330(e) Community Health Centers, Section 330(g) Migrant Health Centers, Section 330(h) Health Care for the Homeless, and Section 330(i) Public Housing Primary Care. In addition, these forms are used by those Health Centers that are applying to be considered a Federally Qualified Health Center (FQHC) Look-Alike. FQHC Look-Alike organizations do not receive 330 grant dollars but they do receive the same cost based reimbursement and drug pricing benefits as a 330 Health Center. These standardized forms are used across the health center programs for grant and non-grant opportunities. The programs using these forms are as follows: New Access Point Funding (NAP), Service Area Competition (SAC) funding, Expanded Medical Capacity (EMC) awards, and the FQHC Look-Alike program.

FQHC's are authorized to provide primary and preventive services to medically underserved and vulnerable populations facing barriers in accessing these services. Barriers include financial, cultural, linguistic and geographical. FQHC's form an integrated safety net for underserved and uninsured children, adults, migrant workers, homeless individuals, and public housing residents in over 4,000 communities across the country and serve over 15 million persons

2. Purpose and Use of Information

The purpose of these forms is to provide information to HRSA staff and objective panel reviewers in order to evaluate applications for determinations of funding. The FQHC's will use a combination of the application forms to apply for one or more of the various opportunities offered based on their eligibility. Applicants provide information for consideration for the following grants: New Access Point, Expanded Medical Capacity, Service Area Competition awards and the FQHC Look-Alike program.

The New Access Point awards provide support for new delivery sites to provide comprehensive primary and preventive health care services. New access points can be either new start applicants that do not currently receive funding under section 330, or satellites. Satellite applicants currently receive grant support under section 330, and propose to establish a new access point to serve a new patient population. The Expanded Medical Capacity forms are used to apply for funds to support expanding the medical capacity at sites currently operated by organizations receiving support under the Consolidated Health Center Program. This support expands access to primary health care services by increasing penetration into a health center’s current service area. Strategies for expanded medical capacity may include expanding existing primary care medical services, adding new medical providers, expanding hours of operations, or providing additional medical services through contractual relationships. Service Area Competition awards provide support for comprehensive primary and preventive health care service delivery in an underserved area or population. FQHC Look-Alike organizations meet all of the eligibility requirements of an organization that receives a Section 330 grant, but do not receive grant funding. They do receive many of the same benefits as FQHCs, such as automatic designation as a Health Professional Shortage Area (HPSA), and enhanced Medicare and Medicaid reimbursement.

The forms provide information that is required by the Bureau for reviewing applications, monitoring, and ensuring compliance with conditions of award for the programs mentioned above. The following forms are used to collect the required information:

General Information Worksheet: this form provides summary information on the applicant institution.

Planning General Information Worksheet: this form provides summary information for planning grant applicants.

BPHC Funding Request Summary: this form collects program specific project budget estimates.

Health Center Checklist: this form provides a checklist of compliance requirements for applicant organizations regarding staffing, governance, and contracting.

Proposed Staff Profile: this form identifies the total personnel and number of FTEs to staff the funding request.

Income Analysis: this form provides revenue information showing projections for patient service revenue for each year by payment source.

Community Characteristics: this form provides community wide and target population data.

Services Provided: applicants provide information on the range of services that are provided to clients/patients.

Sites Listing: this form provides information on the location and hours of operation of service sites.

Other Site Activities: this form provides information on the location and activities that are provided at additional sites.

Board Member Characteristics: this form provides information on board members, areas of expertise, years of service on the board, etc.

Request for Waiver of Governance Requirements: eligible applicants may request a waiver of governing board requirements. Community Health Center applicants are not eligible. Eligible applicants are organizations seeking support for Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care Funding.

Compliance Matrix: this form consists of a checklist and certification that the applicant organization meets the criteria required for compliance with the funding opportunity.

Health Center Affiliation Certification: this is a certification of compliance with Department policies when the applicant organization has an arrangement or affiliation with another organization.

Need for Assistance: this form provides information on the proposed service area and target population.

Emergency Preparedness: this form is a checklist that provides information on the applicant organization’s emergency preparedness and management plan.

Federal Tort Claim Act (FTCA) form: the FTCA deeming form is used by health centers to have health center employees deemed Federal employees for protection under the FTCA.

Points of Contact Application Form: this form provides contact information on the applicant/grant organization.

3. Use of Improved Information Technology

The data collection forms are completed by applicants or grantees using a web based data collection system that is completely integrated with HRSA Electronic Handbooks (EHBs). The HRSA EHB provides authentication and authorization services to all applicants.

Application data can be submitted using standard web browsers through a Section 508 compliant user interface. The system presents users with electronic forms that clearly communicate what is required and provide assistance in completing their applications. Usability features such as those that pre-fill data from prior year applications based on business rules prevent redundant data entry. Users are able to work on the forms in part, save them online and return to complete them later. Programming rules routinely make edit checks to ensure that the data submitted meets the legislative and programmatic requirements. The users are provided with a summary of what is complete and what is incomplete along with links to jump to the appropriate sections to fix the identified incomplete parts.

4. Efforts to Identify Duplication

The applicant organizational information requested in these forms is unique to these Programs and is not available elsewhere.

5. Involvement of Small Entities

This activity does not have a substantial impact on small entities or small businesses.

6. Consequences if Information Were Collected Less Frequently

If the information is not collected annually the Bureau would be unable to make grant awards. The information is also required in order to monitor the progress of the Health Centers to ensure that they are in compliance of the 330 Statue and Program Expectations.

7. Consistency With Guidelines in 5 CFR 1320.5(d)(2)

The data are collected in a manner consistent with guidelines contained in 5 CFR 1320.5(d) (2).

8. Consultation Outside of the Agency

The notice required by 5 CFR 1320.8(d) was published in the Federal Register on April 3, 2007 (Vol. 72, No. 63, pages 15889-15890). No comments were received.

The guidance and applications were provided to the National Association of Community Health Centers (NACHC) for review of the materials regarding clarity and the estimate of annualized burden. The NACHC members consulted were:

Freda Mitchum

National Association of Community Health Centers

202-659-8008

John Ruiz

Health Systems Specialist

National Association of Community Health Centers

202-659-8008

9. Remuneration of Respondents

Respondents will not be remunerated.

10. Assurance of Confidentiality

No assurance of confidentiality is made to the applicants. These applications specify the reporting of aggregate data on users and the services they receive, in addition to descriptive information about each grantee and its operations and financial systems. Grantee level data are covered under the Freedom of Information Act.

11. Questions of a Sensitive Nature

There are no questions of a sensitive nature.

12. Estimates of Annualized Hour Burden

The burden is as follows:

Form	Number of Respondents	Responses per Respondent	Total Responses	Hours per Response	Total Burden Hours
General Information Worksheet	1,021	1	1,021	3.0	3,063
Planning Information Worksheet	300	1	300	12.0	3,600
Funding Request Summary	1,021	1	1,021	0.5	510.5
Health Center Checklist	1,021	1	1,021	0.5	510.5
Proposed Staff Profile	1,021	1	1,021	6.0	6,126
Income Analysis Form	1,021	1	1,021	15.0	15,315
Community Characteristics	1,021	1	1,021	12.0	12,252
Services Provided	1,021	1	1,021	0.5	510.5
Sites Listing	1,021	1	1,021	1.0	1,021
Other Site Activities	700	1	700	0.5	350
Board Member Characteristics	1,021	1	1,021	1.0	1,021
Waiver of Governance Requirements	150	1	150	1.0	150
Compliance Matrix	1,021	1	1,021	0.5	510.5
Health Center Affiliation Certification	250	1	250	0.5	125
Need for Assistance	900	1	900	6.0	5,400
Emergency Preparedness Form	1,021	1	1,021	1.0	1,021
FTCA Form	800	1	800	1.0	800
Points of Contact	800	1	800	0.5	400
Total	1,021		15,131		52,686

Basis for the estimates:

The burden estimates for the applications and forms were based on previous experience with these forms, and input from grantees using the EHB system and application forms.

The work can be performed by a senior staff person with an average wage rate of $35 per hour.

13. Estimates of Annualized Cost Burden to Respondents

There are no capital or start up costs for the data collection required to complete these applications and forms.

14. Estimated Cost to the Federal Government

The estimated annual cost to the government is approximately $59,800 for reviewing the forms, and for processing and providing notification to applicants.

15. Change in Burden

The OMB Inventory currently contains 59,375 burden hours for this activity. This request is for 52,686 total burden hours, for a decrease of 6,689 hours (this number differs by 2 hours from the ICRAS estimate due to rounding, but is the number that was published in the Federal Register 30 day notice). The decrease is a program adjustment resulting from a decrease in the estimated number of respondents since the last clearance request.

There is a program adjustment in the number of total responses in this submission because each form is being submitted in ICRAS separately rather than as one large application package. In the last clearance request, these forms were submitted together as a single large application package, and applicants would complete only those forms that were applicable to the program to which they sought support. For this clearance request, each form is being submitted separately to more accurately reflect the number of respondents per form. This results in a large increase in the total number of responses as each form is submitted as a single entity. The current number of responses is 1,425, equal to the number of respondents. This request is for 1,021 respondents with a total number of responses of 15,131 because of counting each form separately.

16. Time Schedule, Publication, and Analysis Plans

There will be no statistical analysis done on the information received nor will there be any publication of the information reported on the applications.

17. Exemption for Display of Expiration Date

The expiration date will be displayed.

18. Certifications

This project fully complies with CFR 1320.9. The certifications are included in this package.

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