The Health Center Program Application Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0285-1a General Info Worksheet	Form	Modified	Available
Form 0285-Other Reqs Other Requirements for Sites	Form	Modified	Available
Form 0285-Equipment lis Equipment List	Form	Modified	Repair queued
Form 0285- Assurances Assurances	Form	Modified	Available
Form 0285-Project Impac Capital Improvement_Investment Project Impact	Form	Modified	Available
Form 0285-Project Cover Capital Improvement_Investment Project Cover	Form	Modified	Repair queued
Form 0285-Proposal Cove Capital Improvement_Investment Proposal Cover Page	Form	Modified	Available
Form 0285-Delete Servic CIS_Delete Services Checklist	Form	Modified	Available
Form 0285-Add Services CIS_Add Services Checklist	Form	Modified	Available
Form 0285-Relocate Site CIS-Relocation Site Checklist	Form	Modified	Available
Form 0285-Delete Site C CIS Delete Site Checklist	Form	Modified	Available
Form 0285-Add Site Chec CIS Add Site Checklist	Form	Modified	Available
Form 0285-Business Plan Business Plan- Non Competing	Form	Modified	Available
Form 0285-Business Plan Business Plan- SAC NAP	Form	Modified	Available
Form 0285-12 Points of Contact	Form	Modified	Available
Form 0285-HC Plan-SAC N Health Care Plan- Competing	Form	Modified	Available
Form 0285-10 Annual Emergency Preparedness	Form	Modified	Available
Form 0285-9 Need for Assistance	Form	Modified	Available
Form 0285-8 Health Center Affiliation Certification	Form	Modified	Repair queued
Form 0285- HC Plan- BPR Health Care Plan- Non Competing	Form	Modified	Available
Form 0285-6b Request for Waiver of Governance Requirements	Form	Modified	Available
Form 0285-6a Board Member Characteristics	Form	Modified	Available
Form 0285-5c Other Activities	Form	Modified	Repair queued
Form 0285-5b Service Sites Listing	Form	Modified	Available
Form 0285-5a Services Provided	Form	Modified	Available
Form 0285-4 Community Characteristics	Form	Modified	Available
Form 0285-3 Income Analysis Form	Form	Modified	Available
Form 0285-2 Staffing Profile	Form	Modified	Repair queued
Form 0285-4 Documents on File	Form	Modified	Available
Form 0285-1b Funding Request Summary	Form	Modified	Available
Form 0285-1a Planning Grant-General Info Worksheet	Form	Modified	Available
Memo for nonsubstantive change.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2010-10-25	Available
0285 nfa resource guide.doc	Supplementary Document	Uploaded 2007-06-15	Available
FORM 1A instructions.doc	Supplementary Document	Uploaded 2010-06-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6538	The Health Center Program Application Forms	Form	Modified	General Info Worksheet
193532	The Health Center Program Application Forms	Form	Modified	Other Requirements for Sites
193531	The Health Center Program Application Forms	Form	Modified	Equipment List
193530	The Health Center Program Application Forms	Form	Modified	Assurances
193529	The Health Center Program Application Forms	Form	Modified	Capital Improvement_Investment Project Impact
193528	The Health Center Program Application Forms	Form	Modified	Capital Improvement_Investment Project Cover
193527	The Health Center Program Application Forms	Form	Modified	Capital Improvement_Investment Proposal Cover Page
193526	The Health Center Program Application Forms	Form	Modified	CIS_Delete Services Checklist
193525	The Health Center Program Application Forms	Form	Modified	CIS_Add Services Checklist
193524	The Health Center Program Application Forms	Form	Modified	CIS-Relocation Site Checklist
193523	The Health Center Program Application Forms	Form	Modified	CIS Delete Site Checklist
193522	The Health Center Program Application Forms	Form	Modified	CIS Add Site Checklist
193521	The Health Center Program Application Forms	Form	Modified	Business Plan- Non Competing
193520	The Health Center Program Application Forms	Form	Modified	Business Plan- SAC NAP
180786	The Health Center Program Application Forms	Form	Modified	Points of Contact
180785	The Health Center Program Application Forms	Form	Modified	Health Care Plan- Competing
180784	The Health Center Program Application Forms	Form	Modified	Annual Emergency Preparedness
180783	The Health Center Program Application Forms	Form	Modified	Need for Assistance
180783	The Health Center Program Application Forms	Instruction	Modified
180782	The Health Center Program Application Forms	Form	Modified	Health Center Affiliation Certification
180781	The Health Center Program Application Forms	Form	Modified	Health Care Plan- Non Competing
180780	The Health Center Program Application Forms	Form	Modified	Request for Waiver of Governance Requirements
180779	The Health Center Program Application Forms	Form	Modified	Board Member Characteristics
180778	The Health Center Program Application Forms	Form	Modified	Other Activities
180777	The Health Center Program Application Forms	Form	Modified	Service Sites Listing
180776	The Health Center Program Application Forms	Form	Modified	Services Provided
180775	The Health Center Program Application Forms	Form	Modified	Community Characteristics
180774	The Health Center Program Application Forms	Form	Modified	Income Analysis Form
180773	The Health Center Program Application Forms	Form	Modified	Staffing Profile
180772	The Health Center Program Application Forms	Form	Modified	Documents on File
180771	The Health Center Program Application Forms	Form	Modified	Funding Request Summary
180770	The Health Center Program Application Forms	Form	Modified	Planning Grant-General Info Worksheet

ICR Details

OMB Control No: 0915-0285	ICR Reference No: 201010-0915-006
Status: Historical Active	Previous ICR Reference No: 201007-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: The Health Center Program Application Forms
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/14/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/29/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	10/31/2013	10/31/2013
Responses	22,758	0	22,758
Time Burden (Hours)	37,139	0	37,139
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): PL: Pub.L. 107 - 251 101 Name of Law: Health Centers
   US Code: 42 USC 254b 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

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 31

table that charts list of burden

IC Title	Form No.	Form Name
The Health Center Program Application Forms	0285-12	Points of Contact
The Health Center Program Application Forms	0285- Assurances	Assurances
The Health Center Program Application Forms	0285-1a	Planning Grant-General Info Worksheet
The Health Center Program Application Forms	0285-1b	Funding Request Summary
The Health Center Program Application Forms	0285-HC Plan-SAC NAP	Health Care Plan- Competing
The Health Center Program Application Forms	0285-Business Plan-SAC NAP	Business Plan- SAC NAP
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-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-Delete Site Checklist	CIS Delete Site Checklist
The Health Center Program Application Forms	0285-Delete Services	CIS_Delete Services Checklist
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-Equipment list	Equipment List
The Health Center Program Application Forms	0285-Other Reqs	Other Requirements for Sites
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-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	0285-1a	General Info Worksheet

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ICR Summary of Burden

table that charts list 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	22,758	0	0	0	0
Annual Time Burden (Hours)	37,139	37,139	0	0	0	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:

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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]? No

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: 10/29/2010

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