Cover Memo

The Health Center Program Application Forms— OMB No. 0915-0285

DATE: June 14, 2010

FROM: Reports Clearance Officer, HRSA

TO: Office of Information and Regulatory Affairs, OMB

Through: Reports Clearance Officer, DHHS

SUBJECT: Health Resources and Services Administration –The Health Center Program Application Forms— OMB No. 0915-0285

This is a request for revision to a currently approved OMB approval for the Health Resources and Services Administration’s Health Center Program Application Forms, approved under OMB No. 0915-0285 expiring in 8/31/2010. These application forms provide information to HRSA in order to evaluate applications for funding approval, designation and program monitoring. Health centers will use a combination of the application forms to apply for one or more of the various opportunities offered based on their eligibility.

There are a couple of errors in calculation of burden hours in the 30 day Federal Register Notice (FRN) that published on June 11, 2010 for these application forms. In the attached Supporting Statement, we have corrected the following errors that were found after publication of the 30 day FRN:

• The Health Care Plan (Competing) Application Form will be completed by an estimated 800 respondents with 1 response per respondent resulting in 800 total responses for this form. (In the 30 day FRN, it is erroneously calculated as 1,034 total responses.)

• The Business Plan (Competing) Application Form will be completed by an estimated 800 respondents with 1 response per respondent resulting in 800 total responses for this form. (In the 30 day FRN, it is erroneously calculated as 1,034 total responses.)

• The CIS Service Add Checklist form will be completed by an estimated 100 respondents with 1 response per respondent resulting in 100 total responses for this form, and not the 200 erroneously listed in the 30 day FRN.

• The Electronic Health Record (EHR) Readiness and Environmental Information and Documentation (EID) checklists were erroneously included in the 30 day FRN and have been correctly deleted in the burden table in the Supporting Statement. The burden included for these forms have already been OMB approved and are cleared under separate OMB Control Numbers. The EHR checklist is approved under OMB #0915-0325 and expires 6/30/11 and the EID checklist is approved under OMB #0915-0324 and expires 2/28/2013.

The corrections are highlighted in the below table:

Type of Application Form	Number of Respondents	Responses per Respondent	Total Responses	Hours per Response	Total Burden Hours
General Information Worksheet	1,034	1	1,034	2.0	2,068
Planning Grant: General Information Worksheet	250	1	250	2.5	625
BPHC Funding Request Summary	1,034	1	1,034	2.0	2,068
Documents on File	1,034	1	1,034	1.0	1,034
Proposed Staff Profile	1,034	1	1,034	2.0	2,068
Income Analysis Form	1,034	1	1,034	5.0	5,170
Community Characteristics	1,034	1	1,034	1.0	1,034
Health Care Plan(Competing)	800	1	1,034800	4.0	4,1363,200
Health Care Plan (Non-Competing)	1,034	1	1,034	2.0	2,068
Business Plan (Competing)	800	1	1,034800	4.0	4,1363,200
Business Plan (Non-Competing)	1,034	1	1,034	2.0	2,068
Services Provided	1,034	1	1,034	1.0	1,034
Sites Listing	1,034	1	1,034	1.0	1,034
Other Site Activities	700	1	700	0.5	350
Change In Scope (CIS) Site Add Checklist	300	1	300	1.0	300
CIS Site Delete Checklist	200	1	200	1.0	200
CIS Relocation Checklist	200	1	200	1.5	300
CIS Service Add Checklist	100	1	1200	1.0	1200
CIS Service Delete Checklist	100	1	100	1.0	100
Board Member Characteristics	1,034	1	1,034	1.0	1,034
Request for Waiver of Governance Requirements	150	1	150	1.0	150
Health Center Affiliation Certification	250	1	250	1.0	250
Need for Assistance	900	1	900	3.0	2,700
Emergency Preparedness Form	1,034	1	1,034	1.0	1,034
Points of Contact	800	1	800	0.5	400
EHR Readiness Checklist	250	1	250	1	250
Environmental Information and Documentation Checklist (EID)	400	1	400	2	800
Capital Improvement/ Investment Proposal Cover Page	700	1	700	1.0	700
Capital Improvement/ Investment Project Cover	700	1	700	1.0	700
Capital Improvement/ Investment Project Impact	700	1	700	0.5	350
Assurances	900	1	900	.5	450
Equipment List	900	1	900	1.0	900
Other Requirements for Sites	900	1	900	.5	450
Total	1,034	1	23,97622,758		40,16137,139

The current total burden hours in the OMB inventory for the Health Center Program Application Forms (OMB No. 0915-0285) is 52,688 hours. The revision that is being submitted decreases the total annual burden to 37,139 hours due to revisions as well as program adjustments, which are clarified in the attached Supporting Statement.

Nidhi Singh

4