The Health Center Program Application Forms

Forms and Documents

Document	Type	Status	Availability
Form 0285-1a The Health Center Program Application Forms	Form	Modified	Source copy available
Form 0285-Other Reqs The Health Center Program Application Forms	Form	New	Repair queued
Form 0285-Equipment lis The Health Center Program Application Forms	Form	New	Repair queued
Form 0285- Assurances The Health Center Program Application Forms	Form	New	Repair queued
Form 0285-Project Impac The Health Center Program Application Forms	Form	New	Repair queued
Form 0285-Project Cover The Health Center Program Application Forms	Form	New	Repair queued
Form 0285-Proposal Cove The Health Center Program Application Forms	Form	New	Available
Form 0285-Delete Servic The Health Center Program Application Forms	Form	New	Available
Form 0285-Add Services The Health Center Program Application Forms	Form	New	Repair queued
Form 0285-Relocate Site The Health Center Program Application Forms	Form	New	Repair queued
Form 0285-Delete Site C The Health Center Program Application Forms	Form	New	Repair queued
Form 0285-Add Site Chec The Health Center Program Application Forms	Form	New	Available
Form 0285-Business Plan The Health Center Program Application Forms	Form	New	Available
Form 0285-Business Plan The Health Center Program Application Forms	Form	New	Available
Form 0285-12 The Health Center Program Application Forms	Form	Modified	Repair queued
Form 0285-HC Plan-SAC N The Health Center Program Application Forms	Form	Modified	Repair queued
Form 0285-10 The Health Center Program Application Forms	Form	Modified	Repair queued
Form 0285-8 The Health Center Program Application Forms	Form	Modified	Repair queued
Form 0285- HC Plan- BPR The Health Center Program Application Forms	Form	Modified	Available
Form 0285-6b The Health Center Program Application Forms	Form	Modified	Repair queued
Form 0285-6a The Health Center Program Application Forms	Form	Modified	Available
Form 0285-5c The Health Center Program Application Forms	Form	Modified	Available
Form 0285-5b The Health Center Program Application Forms	Form	Modified	Repair queued
Form 0285-5a The Health Center Program Application Forms	Form	Modified	Repair queued
Form 0285-4 The Health Center Program Application Forms	Form	Modified	Repair queued
Form 0285-3 The Health Center Program Application Forms	Form	Modified	Repair queued
Form 0285-2 The Health Center Program Application Forms	Form	Modified	Available
Form 0285-4 The Health Center Program Application Forms	Form	Modified	Available
Form 0285-1b The Health Center Program Application Forms	Form	Modified	Repair queued
Form 0285-1a The Health Center Program Application Forms	Form	Modified	Repair queued
2010-30 day-0285.pdf	Supplementary Document	Uploaded 2010-06-14	Available
Cover Memo for 0915-0285.doc	Supplementary Document	Uploaded 2010-06-14	Repair queued
0285 nfa resource guide.doc	Supplementary Document	Uploaded 2007-06-15	Repair queued
FORM 1A instructions.doc	Supplementary Document	Uploaded 2010-06-14	Repair queued
ss_0285_submitted_to_OMB-FINAL.post comment 7.22.10.docx	Supporting Statement A	Uploaded 2010-07-28	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
6538	The Health Center Program Application Forms	Form	Modified
193532	The Health Center Program Application Forms	Form	New
193531	The Health Center Program Application Forms	Form	New
193530	The Health Center Program Application Forms	Form	New
193529	The Health Center Program Application Forms	Form	New
193528	The Health Center Program Application Forms	Form	New
193527	The Health Center Program Application Forms	Form	New
193526	The Health Center Program Application Forms	Form	New
193525	The Health Center Program Application Forms	Form	New
193524	The Health Center Program Application Forms	Form	New
193523	The Health Center Program Application Forms	Form	New
193522	The Health Center Program Application Forms	Form	New
193521	The Health Center Program Application Forms	Form	New
193520	The Health Center Program Application Forms	Form	New
180786	The Health Center Program Application Forms	Form	Modified
180785	The Health Center Program Application Forms	Form	Modified
180784	The Health Center Program Application Forms	Form	Modified
180783	The Health Center Program Application Forms	Instruction	Modified
180782	The Health Center Program Application Forms	Form	Modified
180781	The Health Center Program Application Forms	Form	Modified
180780	The Health Center Program Application Forms	Form	Modified
180779	The Health Center Program Application Forms	Form	Modified
180778	The Health Center Program Application Forms	Form	Modified
180777	The Health Center Program Application Forms	Form	Modified
180776	The Health Center Program Application Forms	Form	Modified
180775	The Health Center Program Application Forms	Form	Modified
180774	The Health Center Program Application Forms	Form	Modified
180773	The Health Center Program Application Forms	Form	Modified
180772	The Health Center Program Application Forms	Form	Modified
180771	The Health Center Program Application Forms	Form	Modified
180770	The Health Center Program Application Forms	Form	Modified

ICR Details

OMB Control No: 0915-0285	ICR Reference No: 201007-0915-001
Status: Historical Active	Previous ICR Reference No: 200706-0915-005
Agency/Subagency: HHS/HSA	Agency Tracking No:
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 without change	Conclusion Date: 10/04/2010
	Date Received in OIRA: 07/01/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	36 Months From Approved	10/31/2010
Responses	22,758	0	15,131
Time Burden (Hours)	37,139	0	52,688
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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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

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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:
	75 FR 15436	03/29/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 33310	06/11/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 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

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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	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

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: No

Burden Reduction Due to:

Short Statement: 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.

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Annual Cost to Federal Government: $138,000

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]? Uncollected

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: 07/01/2010

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