Free Clinics FTCA Program Application

Forms and Documents

Document Name	Status
Form 1 Free Clinics FTCA Program Application Form and Instruction	Modified
Supporting Statement A.doc Supporting Statement A	2014-08-19

IC Document Collections

IC ID	Document Title	Status
6548	Free Clinics FTCA Program Application Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0293	ICR Reference No: 201408-0915-001
Status: Historical Active	Previous ICR Reference No: 201108-0915-003
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Free Clinics FTCA Program Application
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: 10/07/2014
	Date Received in OIRA: 08/28/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2017	36 Months From Approved	12/31/2014
Responses	227	0	200
Time Burden (Hours)	454	0	2,800
Cost Burden (Dollars)	0	0	0

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Abstract: The Free Clinics FTCA program application is used to determine if the free clinic volunteer health professionals meet the statutory requirements for deeming the health care professional as a Federal employee for the purposes of Federal Tort Claims Act (FTCA) medical malpractice protection. If the requirements of the Act are met, the related free clinic can be sponsored to be "deemed" a federal employee for the purpose of FTCA medical malpractice coverage.

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Authorizing Statute(s): PL: Pub.L. 104 - 191 224 Name of Law: Free Clinics Federal Tort Claim Act
   US Code: 42 USC 233(o) Name of Law: Health Insurance Portability and Accountability Act of 1996
  

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:
	79 FR 34765	06/18/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 47655	08/14/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Free Clinics FTCA Program Application	1	FTCA Free Clinic Application

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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	227	200	0	27	0	0
Annual Time Burden (Hours)	454	2,800	0	-2,346	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: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: There is a change to the estimate of burden. The number of hours per Free Clinic application has been reduced from fourteen (14) to two (2) hours due to the Free Clinic deeming application module, which is the new electronic application submitted to HRSA through the Electronic Handbooks. The number of respondents has also increased to 227. As a result the total number of burden hours has decreased to 454.

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Annual Cost to Federal Government: $87,583

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: 08/28/2014

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