The Health Center Program Application Forms

ICR 201007-0915-001

OMB: 0915-0285

Federal Form Document

Forms and Documents
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Supplementary Document
2010-06-14
Supplementary Document
2010-06-14
Supplementary Document
2007-06-15
Supplementary Document
2010-06-14
Supporting Statement A
2010-07-28
IC Document Collections
IC ID
Document
Title
Status
6538 Modified
193532 New
193531 New
193530 New
193529 New
193528 New
193527 New
193526 New
193525 New
193524 New
193523 New
193522 New
193521 New
193520 New
180786 Modified
180785 Modified
180784 Modified
180783 Modified
180782 Modified
180781 Modified
180780 Modified
180779 Modified
180778 Modified
180777 Modified
180776 Modified
180775 Modified
180774 Modified
180773 Modified
180772 Modified
180771 Modified
180770 Modified
ICR Details
0915-0285 201007-0915-001
Historical Active 200706-0915-005
HHS/HSA
The Health Center Program Application Forms
Revision of a currently approved collection   No
Regular
Approved without change 10/04/2010
Retrieve Notice of Action (NOA) 07/01/2010
  Inventory as of this Action Requested Previously Approved
10/31/2013 36 Months From Approved 10/31/2010
22,758 0 15,131
37,139 0 52,688
0 0 0

This ICR contains revisions to 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.

US Code: 42 USC 254b Name of Law: Health Centers
   PL: Pub.L. 107 - 251 101 Name of Law: Health Centers
  
None

Not associated with rulemaking

  75 FR 15436 03/29/2010
75 FR 33310 06/11/2010
No

31
IC Title Form No. Form Name
The Health Center Program Application Forms 0285-1b Funding Request Summary
The Health Center Program Application Forms 0285-4 Documents on File
The Health Center Program Application Forms 0285-2 Staffing Profile
The Health Center Program Application Forms 0285-3 Income Analysis Form
The Health Center Program Application Forms 0285-4 Community Characteristics
The Health Center Program Application Forms 0285-5a Services Provided
The Health Center Program Application Forms 0285-5b Service Sites Listing
The Health Center Program Application Forms 0285-5c Other Activities
The Health Center Program Application Forms 0285-6a Board Member Characteristics
The Health Center Program Application Forms 0285-6b Request for Waiver of Governance Requirements
The Health Center Program Application Forms 0285- HC Plan- BPR Health Care Plan- Non Competing
The Health Center Program Application Forms 0285-8 Health Center Affiliation Certification
The Health Center Program Application Forms 0285-9 Need for Assistance
The Health Center Program Application Forms 0285-10 Annual Emergency Preparedness
The Health Center Program Application Forms 0285-HC Plan-SAC NAP Health Care Plan- Competing
The Health Center Program Application Forms 0285-12 Points of Contact
The Health Center Program Application Forms 0285-Business Plan-SAC NAP Business Plan- SAC NAP
The Health Center Program Application Forms 0285-Business Plan-BPR Business Plan- Non Competing
The Health Center Program Application Forms 0285-Add Site Checklist CIS Add Site Checklist
The Health Center Program Application Forms 0285-1a General Info Worksheet
The Health Center Program Application Forms 0285-1a Planning Grant-General Info Worksheet
The Health Center Program Application Forms 0285-Proposal Cover Pg Capital Improvement_Investment Proposal Cover Page
The Health Center Program Application Forms 0285-Project Cover Capital Improvement_Investment Project Cover
The Health Center Program Application Forms 0285-Project Impact Capital Improvement_Investment Project Impact
The Health Center Program Application Forms 0285- Assurances Assurances
The Health Center Program Application Forms 0285-Equipment list Equipment List
The Health Center Program Application Forms 0285-Other Reqs Other Requirements for Sites
The Health Center Program Application Forms 0285-Delete Site Checklist CIS Delete Site Checklist
The Health Center Program Application Forms 0285-Relocate Site CIS-Relocation Site Checklist
The Health Center Program Application Forms 0285-Add Services CIS_Add Services Checklist
The Health Center Program Application Forms 0285-Delete Services CIS_Delete Services Checklist

  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 22,758 15,131 0 7,547 80 0
Annual Time Burden (Hours) 37,139 52,688 0 13,775 -29,324 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
The total annual burden for this activity has decreased by 15,549 hours while the total responses have increased by 7,627 from the last approval. The decrease of 29,324 hours is due to program adjustments resulting from streamlining application forms, electronic structuring of forms and re-assessing the previous burden hours since the last approval. There has been a program change increase in burden hours by 13,775 hours and 7,547 responses as a result of newly added application forms. The net total annual burden for this activity is 37,139 hours.

$138,000
No
No
No
Uncollected
No
Uncollected
Susan Queen 3014431129

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/01/2010


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