The Health Center Program Application Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 General Information Worksheet	Form	Modified	Available
Form 1 Supplemental Line Item Budget	Form and Instruction	Modified	Available
Form 1 O&E Progress Report	Form	Modified	Available
Form 1 O&E Supplemental	Form	Modified	Repair queued
Form 1 Look Alike Budget	Form	Modified	Repair queued
Form 1 EHR Readiness Checklist	Form	Modified	Available
Form 1 Verification Checklist	Form	Modified	Available
Form 1 Project Work Plan	Form	Modified	Available
Form 1 Implementation Plan	Form	Modified	Available
Form 1 Project Qualification Criteria	Form	Modified	Repair queued
Form 1 Funding Sources	Form	Modified	Repair queued
Form 1 Increased demand for services	Form	Modified	Available
Form 1 checklist for adding a new target population	Form	Modified	Available
Form 1 Other Requirements for Sites	Form	Modified	Available
Form 1 Equipment List	Form	Modified	Available
Form 1 Project Cover Page	Form	Modified	Available
Form 1 Proposal Cover Page	Form	Modified	Repair queued
Form 1 Checklist for Deleting Existing Service Delivery Site	Form	Modified	Repair queued
Form 1 Checklist for Adding a New Service Delivery Site	Form	Modified	Available
Form 1 Checklist for replacing existing service delivery site	Form	Modified	Available
Form 1 Checklist for deleting existing service	Form	Modified	Available
Form 1 Checklist for adding new service	Form	Modified	Available
Form 1 Financial Performance Measures	Form	Modified	Available
Form 12 Organization Contacts	Form	Modified	Available
Form 1 Clinical Performance Measures	Form	Modified	Available
Form 10 Annual Emergency Preparedness Report	Form	Modified	Available
Form 9 Need for Assistance Worksheet	Form	Modified	Available
Form 8 Health Center Agreements	Form	Modified	Available
Form 6b Request for waiver of governance requirements	Form	Modified	Available
Form 6a Current Board Member Characteristics	Form	Modified	Available
Form 5c other activities/locations	Form	Modified	Available
Form 5b Service Sites	Form	Modified	Available
Form 5a Services Provided	Form	Modified	Available
Form 4 Community Characteristics	Form	Modified	Repair queued
Form 3 Income Analysis	Form	Modified	Available
Form 2 Staffing Profile	Form	Modified	Available
Form 1C Documents on File	Form	Modified	Available
Form 1B Funding Request Summary	Form	Modified	Available
Title X outreach and enrollment sample data collection form.docx	Supplementary Document	Uploaded 2013-12-17	Available
Non-Sub Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2013-12-06	Available
Supporting Statement.docx	Supporting Statement A	Uploaded 2013-12-03	Available

IC Document Collections

Information collection document groups

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

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
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/20/2013
Terms of Clearance:

table that charts list comparision

	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

table that charts list of burden

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

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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	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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