The Health Center Program Application Forms

Forms and Documents

Document Name	Status
Form 1 General Information Worksheet Form	Modified
Form 1 Supplemental Line Item Budget Form and Instruction	Modified
Form 1 Oamp;E Progress Report Form	Modified
Form 1 Oamp;E Supplemental Form	Modified
Form 1 Look Alike Budget Form	Modified
Form 1 EHR Readiness Checklist Form	Modified
Form 1 Verification Checklist Form	Modified
Form 1 Project Work Plan Form	Modified
Form 1 Implementation Plan Form	Modified
Form 1 Project Qualification Criteria Form	Modified
Form 1 Funding Sources Form	Modified
Form 1 Increased Demand for Services Form	Modified
Form 1 Checklist for Adding a New Target Population Form	Modified
Form 1 Other Requirements for Sites Form	Modified
Form 1 Equipment List Form	Modified
Form 1 Project Cover Page Form	Modified
Form 1 Proposal Cover Page Form	Modified
Form 1 Checklist for Deleting Existing Service Delivery Site Form	Modified
Form 1 Checklist for Adding a new Service Delivery Site Form	Modified
Form 1 Checklist for Replacing Existing Service Delivery Site Form	Modified
Form 1 Checklist for Deleting Existing Service Form	Modified
Form 1 Checklist for Adding New Service Form	Modified
Form 1 Financial Performance Measures Form	Modified
Form 12 Organization Contacts Form	Modified
Form 1 Clinical Performance Measures Form	Modified
Form 10 Annual Emergency Preparedness Report Form	Modified
Form 9 Need for Assitance Worksheet Form	Modified
Form 8 Health Center Agreements Form	Modified
Form 6b Request for Waiver of Governance Requirements Form	Modified
Form 6a Current Board Member Characteristics Form	Modified
Form 5c Other Activities/Locations Form	Modified
Form 5b Service Sites Form	Modified
Form 5a Services Provided Form	Modified
Form 4 Community Characteristics Form	Modified
Form 3 Income Analysis Form	Modified
Form 2 Staffing Profile Form	Modified
Form 1C Documents on File Form	Modified
Form 1B Funding Request Summary Form	Modified
Title X outreach and enrollment sample data collection form.docx Supplementary Document	2013-12-17
Non-Sub Change Request.docx Justification for No Material/Nonsubstantive Change	2013-12-06
Supporting Statement.docx Supporting Statement A	2013-12-03

IC Document Collections

IC ID	Document Title	Status
6538	General Information Worksheet Form	Modified
207854	Supplemental Line Item Budget Form and Instruction	Modified
207853	Oamp;E Progress Report Form	Modified
207852	Oamp;E Supplemental Form	Modified
207851	Look Alike Budget Form	Modified
207850	EHR Readiness Checklist Form	Modified
207849	Verification Checklist Form	Modified
207848	Project Work Plan Form	Modified
207847	Implementation Plan Form	Modified
207846	Project Qualification Criteria Form	Modified
207845	Funding Sources Form	Modified
207844	Increased Demand for Services Form	Modified
207843	Checklist for Adding a New Target Population Form	Modified
193532	Other Requirements for Sites Form	Modified
193531	Equipment List Form	Modified
193528	Project Cover Page Form	Modified
193527	Proposal Cover Page Form	Modified
193526	Checklist for Deleting Existing Service Delivery Site Form	Modified
193525	Checklist for Adding a new Service Delivery Site Form	Modified
193524	Checklist for Replacing Existing Service Delivery Site Form	Modified
193523	Checklist for Deleting Existing Service Form	Modified
193522	Checklist for Adding New Service Form	Modified
193520	Financial Performance Measures Form	Modified
180786	Organization Contacts Form	Modified
180785	Clinical Performance Measures Form	Modified
180784	Annual Emergency Preparedness Report Form	Modified
180783	Need for Assitance Worksheet Form	Modified
180781	Health Center Agreements Form	Modified
180780	Request for Waiver of Governance Requirements Form	Modified
180779	Current Board Member Characteristics Form	Modified
180778	Other Activities/Locations Form	Modified
180777	Service Sites Form	Modified
180776	Services Provided Form	Modified
180775	Community Characteristics Form	Modified
180774	Income Analysis Form	Modified
180773	Staffing Profile Form	Modified
180772	Documents on File Form	Modified
180771	Funding Request Summary Form	Modified

ICR Details

OMB Control No: 0915-0285	ICR Reference No: 201312-0915-005
Status: Historical Active	Previous ICR Reference No: 201307-0915-005
Agency/Subagency: HHS/HSA	Agency Tracking No: 21063
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: 01/02/2014
	Date Received in OIRA: 12/20/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	09/30/2016	09/30/2016
Responses	32,640	0	32,450
Time Burden (Hours)	45,015	0	44,825
Cost Burden (Dollars)	0	0	0

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Abstract: Health Center Program forms are critical to the Program grant and non-grant award process, as well as to Program oversight and monitoring activities. These forms are used by health centers to request funding under Section 330 of the Public Health Service (PHS) Act, change their scope of project and become designated as Look-Alikes. Over 1,200 health centers deliver comprehensive, high quality, cost-effective primary health care to America's most vulnerable populations.

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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
   PL: Pub.L. 111 - 148 5601 Name of Law: Patient Protection and Affordable Care Act of 2010
   PL: Pub.L. 111 - 148 10503 Name of Law: Patient Protection and Affordable Care Act of 2010
   PL: Pub.L. 111 - 152 2303 Name of Law: Health Care and Educational Reconciliation Act of 2010
  

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: 38

IC Title	Form No.	Form Name
Staffing Profile	2	Staffing Profile
Income Analysis	3	Income Analysis
Community Characteristics	4	Community Characteristics
Services Provided	5a	Services Provided
Service Sites	5b	Service Sites
Other Activities/Locations	5c	other activities/locations
Current Board Member Characteristics	6a	Current Board Member Characteristics
Request for Waiver of Governance Requirements	6b	Request for waiver of governance requirements
Health Center Agreements	8	Health Center Agreements
Need for Assitance Worksheet	9	Need for Assistance Worksheet
Annual Emergency Preparedness Report	10	Annual Emergency Preparedness Report
Clinical Performance Measures	1	Clinical Performance Measures
Organization Contacts	12	Organization Contacts
Funding Request Summary	1B	Funding Request Summary
Documents on File	1C	Documents on File
Financial Performance Measures	1	Financial Performance Measures
Checklist for Adding New Service	1	Checklist for adding new service
Checklist for Deleting Existing Service	1	Checklist for deleting existing service
Checklist for Replacing Existing Service Delivery Site	1	Checklist for replacing existing service delivery site
Checklist for Adding a new Service Delivery Site	1	Checklist for Adding a New Service Delivery Site
Checklist for Deleting Existing Service Delivery Site	1	Checklist for Deleting Existing Service Delivery Site
Proposal Cover Page	1	Proposal Cover Page
Project Cover Page	1	Project Cover Page
Equipment List	1	Equipment List
Other Requirements for Sites	1	Other Requirements for Sites
Checklist for Adding a New Target Population	1	checklist for adding a new target population
Increased Demand for Services	1	Increased demand for services
Funding Sources	1	Funding Sources
Project Qualification Criteria	1	Project Qualification Criteria
Implementation Plan	1	Implementation Plan
Project Work Plan	1	Project Work Plan
Verification Checklist	1	Verification Checklist
EHR Readiness Checklist	1	EHR Readiness Checklist
Look Alike Budget	1	Look Alike Budget
Oamp;E Supplemental	1	O&E Supplemental
Oamp;E Progress Report	1	O&E Progress Report
Supplemental Line Item Budget	1	Supplemental Line Item Budget
General Information Worksheet	1	General Information Worksheet

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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	32,640	32,450	0	190	0	0
Annual Time Burden (Hours)	45,015	44,825	0	190	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]? Yes

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: 12/20/2013

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