The Health Center Program Application Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1A General Information Worksheet	Form	Modified	Available
Form 42 Zika Progress Report.pdf	Form and Instruction	New	Available
Form 41 HCCN Work Plan 2016 Cohort.pdf	Form	New	Available
Form 41 HCCN Work Plan (track changes)	Form	New	Available
Form 40 HCCN Progress Report Final	Form	New	Available
Form 40 HCCN Progress Report (track changes)	Form	New	Available
Form 39 Substance Abuse Progress Report	Form and Instruction	New	Available
Form 38 Program Narrative Update 2017	Form and Instruction	New	Available
Form 37 Summary Page 2017.docx	Form	New	Available
Form 35 Supplemental Line_Item_Budget (track changes).docx	Form and Instruction	New	Available
Form 35 Federal Object Class Categories 2017	Form and Instruction	New	Available
Form 36 Supplemental 2017.docx	Form and Instruction	Modified	Available
Form 28 OE Progress_Report 2017 Final	Form and Instruction	Modified	Available
Form 28 OE Progress_Report (track changes)	Form and Instruction	Modified	Available
Form 27 Outreach and Enrollment Supplemental 2017 Final	Form and Instruction	Modified	Available
Form 27 Outreach and Enrollment Supplemental form (track changes).docx	Form and Instruction	Modified	Available
Form 1 Look Alike Budget	Form	Removed	Available
Form 1 EHR Readiness Checklist	Form	Removed	Available
Form 1 Verification Checklist	Form	Removed	Available
Form 20 Project Work Plan Final	Form and Instruction	Modified	Available
Form 20 Project Work Plan (track changes)	Form and Instruction	Modified	Available
Form 19 Implementation plan 2017 Final	Form	Modified	Available
Form 19 Implementation Plan (track changes)	Form	Modified	Available
Form 26 Project Qualification Criteria 2017 Final	Form and Instruction	Modified	Available
Form 26 Project Qualification Criteria (track changes)	Form and Instruction	Modified	Available
Form 25 Funding Sources 2017 Final	Form and Instruction	Modified	Available
Form 25 Funding Sources (track changes)	Form and Instruction	Modified	Available
Form 34 Increased Demand for Services (track changes)	Form and Instruction	Modified	Available
Form 34 Expanded Services	Form and Instruction	Modified	Available
Form 33 Checklist for Adding a New Target Population - track changes	Form and Instruction	Modified	Available
Form 24 Other requirement for sites 2017 Final	Form and Instruction	Modified	Available
Form 24 Other requirement for sites (track changes)	Form and Instruction	Modified	Available
Form 23 Equipment List Final	Form and Instruction	Modified	Available
Form 23 Equipment List (track changes)	Form and Instruction	Modified	Available
Form 22 Project Cover Page (track changes)	Form and Instruction	Modified	Available
Form 21 Proposal Cover Page 2017 Final	Form and Instruction	Modified	Available
Form 21 Proposal Cover Page (track changes)	Form and Instruction	Modified	Available
Form 30 Checklist for Deleting Existing Service Delivery Site 2017 Final	Form and Instruction	Modified	Available
Form 30 Checklist for Deleting Existing Service Delivery Site - track changes	Form and Instruction	Modified	Available
Form 29 Checklist for Adding a New Service Delivery Site 2017 Final	Form and Instruction	Modified	Available
Form 29 Checklist for Adding a New Service Delivery Site - track changes	Form and Instruction	Modified	Available
Form 1 Checklist for replacing existing service delivery site	Form	Removed	Available
Form 32 Checklist for Deleting Existing Service 2017 Final	Form and Instruction	Modified	Available
Form 32 Checklist for Deleting Existing Service - track changes.docx	Form and Instruction	Modified	Available
Form 31 Checklist for Adding New Service 2017 Final	Form and Instruction	Modified	Available
Form 31 Checklist for Adding New Service - track changes	Form and Instruction	Modified	Available
Form 18 Financial Performance Measures (track changes)	Form	Modified	Available
Form 12 Organization Contacts Final	Form	Modified	Available
Form 12 Organization Contacts	Form	Modified	Available
Form 17 Clinical Performance Measures Final	Form	Modified	Available
Form 17 Clinical Performance Measures (track changes)	Form	Modified	Available
Form 10 Emergency Preparedness Report Final	Form	Modified	Available
Form 10 Emergency Preparedness Report	Form	Modified	Available
Form 9 Need for Assistance Worksheet Final	Form	Modified	Available
Form 9 Need for Assistance Worksheet	Form	Modified	Available
Form 8 Health Center Agreements Final	Form and Instruction	Modified	Available
Form 8 Health Center Agreements	Form and Instruction	Modified	Available
Form 6B Request for Waiver of Board Member Final	Form and Instruction	Modified	Available
Form 6B Request for Waiver of Board Member	Form and Instruction	Modified	Available
Form 6A Current Board Member Characteristics Final	Form	Modified	Available
Form 6A Current Board Member Characteristics	Form	Modified	Available
Form 5C Other Activities/Locations Final	Form	Modified	Available
Form 5C Other Activities/Locations	Form	Modified	Available
Form 5B Service Sites	Form	Modified	Available
Form 5A Services Provided Final	Form	Modified	Available
Form 5A Services Provided	Form	Modified	Available
Form 4 Community Characteristics Final	Form	Modified	Available
Form 4 Community Characteristics	Form	Modified	Available
Form 3A Look Alike Budget Information Final	Form and Instruction	Modified	Available
Form 3A Look alike Budget	Form and Instruction	Modified	Available
Form 3 Income Analysis Final	Form	Modified	Available
Form 3 Income Analysis	Form	Modified	Available
Form 2 Staffing Profile Final	Form	Modified	Available
Form 2 Staffing Profile	Form	Modified	Available
Form 1C Documents on File	Form	Modified	Available
Form 1B BPHC Funding Request Summary Final	Form	Modified	Available
Form 1B BPHC Funding Request Summary	Form	Modified	Available
Performance Measures Instructions.docx	Supplementary Document	Uploaded 2016-08-16	Available
Implementation Plan Instructions.docx	Supplementary Document	Uploaded 2016-08-16	Available
Program Specific Forms Instructions.docx	Supplementary Document	Uploaded 2016-08-16	Available
FINAL0285Forms Supporting Statement PASSBACK CLEAN.docx	Supporting Statement A	Uploaded 2017-01-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6538	General Information Worksheet	Form	Modified	General Information Worksheet
6538	General Information Worksheet	Instruction	Modified
223047	Zika Progress Report	Form and Instruction	New	Zika Progress Report.pdf
223046	Health Center Controlled Networks Work Plan	Form	New	HCCN Work Plan 2016 Cohort.pdf
223046	Health Center Controlled Networks Work Plan	Form	New	HCCN Work Plan (track changes)
223045	Health Center Controlled Networks Progress Report	Form	New	HCCN Progress Report Final
223045	Health Center Controlled Networks Progress Report	Form	New	HCCN Progress Report (track changes)
223043	Substance Abuse Progress Report	Form and Instruction	New	Substance Abuse Progress Report
223042	Program Narrative Update	Form and Instruction	New	Program Narrative Update 2017
223041	Summary Page	Form	New	Summary Page 2017.docx
223040	Federal Object Class Categories	Form and Instruction	New	Supplemental Line_Item_Budget (track changes).docx
223040	Federal Object Class Categories	Form and Instruction	New	Federal Object Class Categories 2017
207854	Supplemental Information	Form and Instruction	Modified	Supplemental 2017.docx
207853	O & E Progress Report	Form and Instruction	Modified	OE Progress_Report 2017 Final
207853	O & E Progress Report	Form and Instruction	Modified	OE Progress_Report (track changes)
207852	O & E Supplemental	Form and Instruction	Modified	Outreach and Enrollment Supplemental 2017 Final
207852	O & E Supplemental	Form and Instruction	Modified	Outreach and Enrollment Supplemental form (track changes).docx
207851	Look Alike Budget	Form	Removed	Look Alike Budget
207850	EHR Readiness Checklist	Form	Removed	EHR Readiness Checklist
207849	Verification Checklist	Form	Removed	Verification Checklist
207848	Project Work Plan	Form and Instruction	Modified	Project Work Plan Final
207848	Project Work Plan	Form and Instruction	Modified	Project Work Plan (track changes)
207847	Implementation Plan	Form	Modified	Implementation plan 2017 Final
207847	Implementation Plan	Form	Modified	Implementation Plan (track changes)
207847	Implementation Plan	Instruction	Modified
207846	Project Qualification Criteria	Form and Instruction	Modified	Project Qualification Criteria 2017 Final
207846	Project Qualification Criteria	Form and Instruction	Modified	Project Qualification Criteria (track changes)
207845	Funding Sources	Form and Instruction	Modified	Funding Sources 2017 Final
207845	Funding Sources	Form and Instruction	Modified	Funding Sources (track changes)
207844	Expanded Services	Form and Instruction	Modified	Increased Demand for Services (track changes)
207844	Expanded Services	Form and Instruction	Modified	Expanded Services
207843	Checklist for Adding a New Target Population	Form and Instruction	Modified	Checklist for Adding a New Target Population - track changes
193532	Other Requirements for Sites	Form and Instruction	Modified	Other requirement for sites 2017 Final
193532	Other Requirements for Sites	Form and Instruction	Modified	Other requirement for sites (track changes)
193531	Equipment List	Form and Instruction	Modified	Equipment List Final
193531	Equipment List	Form and Instruction	Modified	Equipment List (track changes)
193528	Project Cover Page	Form and Instruction	Modified	Project Cover Page (track changes)
193527	Proposal Cover Page	Form and Instruction	Modified	Proposal Cover Page 2017 Final
193527	Proposal Cover Page	Form and Instruction	Modified	Proposal Cover Page (track changes)
193526	Checklist for Deleting Existing Service Delivery Site	Form and Instruction	Modified	Checklist for Deleting Existing Service Delivery Site 2017 Final
193526	Checklist for Deleting Existing Service Delivery Site	Form and Instruction	Modified	Checklist for Deleting Existing Service Delivery Site - track changes
193525	Checklist for Adding a new Service Delivery Site	Form and Instruction	Modified	Checklist for Adding a New Service Delivery Site 2017 Final
193525	Checklist for Adding a new Service Delivery Site	Form and Instruction	Modified	Checklist for Adding a New Service Delivery Site - track changes
193524	Checklist for Replacing Existing Service Delivery Site	Form	Removed	Checklist for replacing existing service delivery site
193523	Checklist for Deleting Existing Service	Form and Instruction	Modified	Checklist for Deleting Existing Service 2017 Final
193523	Checklist for Deleting Existing Service	Form and Instruction	Modified	Checklist for Deleting Existing Service - track changes.docx
193522	Checklist for Adding New Service	Form and Instruction	Modified	Checklist for Adding New Service 2017 Final
193522	Checklist for Adding New Service	Form and Instruction	Modified	Checklist for Adding New Service - track changes
193520	Financial Performance Measures	Form	Modified	Financial Performance Measures (track changes)
193520	Financial Performance Measures	Instruction	Modified
180786	Organization Contacts	Form	Modified	Organization Contacts Final
180786	Organization Contacts	Form	Modified	Organization Contacts
180785	Clinical Performance Measures	Form	Modified	Clinical Performance Measures Final
180785	Clinical Performance Measures	Form	Modified	Clinical Performance Measures (track changes)
180784	Annual Emergency Preparedness Report	Form	Modified	Emergency Preparedness Report Final
180784	Annual Emergency Preparedness Report	Form	Modified	Emergency Preparedness Report
180783	Need for Assitance Worksheet	Form	Modified	Need for Assistance Worksheet Final
180783	Need for Assitance Worksheet	Form	Modified	Need for Assistance Worksheet
180781	Health Center Agreements	Form and Instruction	Modified	Health Center Agreements Final
180781	Health Center Agreements	Form and Instruction	Modified	Health Center Agreements
180780	Request for Waiver of Governance Requirements	Form and Instruction	Modified	Request for Waiver of Board Member Final
180780	Request for Waiver of Governance Requirements	Form and Instruction	Modified	Request for Waiver of Board Member
180779	Current Board Member Characteristics	Form	Modified	Current Board Member Characteristics Final
180779	Current Board Member Characteristics	Form	Modified	Current Board Member Characteristics
180778	Other Activities/Locations	Form	Modified	Other Activities/Locations Final
180778	Other Activities/Locations	Form	Modified	Other Activities/Locations
180777	Service Sites	Form	Modified	Service Sites
180776	Services Provided	Form	Modified	Services Provided Final
180776	Services Provided	Form	Modified	Services Provided
180775	Community Characteristics	Form	Modified	Community Characteristics Final
180775	Community Characteristics	Form	Modified	Community Characteristics
180774	Income Analysis	Form and Instruction	Modified	Look Alike Budget Information Final
180774	Income Analysis	Form and Instruction	Modified	Look alike Budget
180774	Income Analysis	Form	Modified	Income Analysis Final
180774	Income Analysis	Form	Modified	Income Analysis
180773	Staffing Profile	Form	Modified	Staffing Profile Final
180773	Staffing Profile	Form	Modified	Staffing Profile
180772	Documents on File	Form	Modified	Documents on File
180771	Funding Request Summary	Form	Modified	BPHC Funding Request Summary Final
180771	Funding Request Summary	Form	Modified	BPHC Funding Request Summary

ICR Details

OMB Control No: 0915-0285	ICR Reference No: 201608-0915-003
Status: Historical Active	Previous ICR Reference No: 201410-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No: 21063
Title: The Health Center Program Application Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/30/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/16/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved	01/31/2017
Responses	35,566	0	32,450
Time Burden (Hours)	44,608	0	44,825
Cost Burden (Dollars)	0	0	0

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Abstract: Health Center Program-specific forms provide information essential for application evaluation, funding and designation recommendation and approval, monitoring, and ensuring compliance with Health Center Program legislative and regulatory requirements. The forms are/will be used by existing health centers and other organizations to apply for grant and non-grant opportunities, renew grant or non-grant designation, and change scope of project.

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Authorizing Statute(s): US Code: 42 USC 254b Section 330 Name of Law: Health Centers, Public Health Service Act, as amended
  

Citations for New Statutory Requirements: US Code: 42 USC 300, Section 1006[c] Name of Law: Public Health Service Act

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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:
	81 FR 41	03/02/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 156	08/12/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 41

table that charts list of burden

IC Title	Form No.	Form Name
Annual Emergency Preparedness Report	10, 10	Emergency Preparedness Report ,   Emergency Preparedness Report Final
Checklist for Adding New Service	31, 31	Checklist for Adding New Service - track changes ,   Checklist for Adding New Service 2017 Final
Checklist for Adding a New Target Population	33	Checklist for Adding a New Target Population - track changes
Checklist for Adding a new Service Delivery Site	29, 29	Checklist for Adding a New Service Delivery Site - track changes ,   Checklist for Adding a New Service Delivery Site 2017 Final
Checklist for Deleting Existing Service	32, 32	Checklist for Deleting Existing Service - track changes.docx ,   Checklist for Deleting Existing Service 2017 Final
Checklist for Deleting Existing Service Delivery Site	30, 30	Checklist for Deleting Existing Service Delivery Site - track changes ,   Checklist for Deleting Existing Service Delivery Site 2017 Final
Checklist for Replacing Existing Service Delivery Site	1	Checklist for replacing existing service delivery site
Clinical Performance Measures	17, 17	Clinical Performance Measures (track changes) ,   Clinical Performance Measures Final
Community Characteristics	4, 4	Community Characteristics ,   Community Characteristics Final
Current Board Member Characteristics	6A, 6A	Current Board Member Characteristics ,   Current Board Member Characteristics Final
Documents on File	1C	Documents on File
EHR Readiness Checklist	1	EHR Readiness Checklist
Equipment List	23, 23	Equipment List (track changes) ,   Equipment List Final
Expanded Services	34, 34	Expanded Services ,   Increased Demand for Services (track changes)
Federal Object Class Categories	35, 35	Federal Object Class Categories 2017 ,   Supplemental Line_Item_Budget (track changes).docx
Financial Performance Measures	18	Financial Performance Measures (track changes)
Funding Request Summary	1B, 1B	BPHC Funding Request Summary ,   BPHC Funding Request Summary Final
Funding Sources	25, 25	Funding Sources (track changes) ,   Funding Sources 2017 Final
General Information Worksheet	1A	General Information Worksheet
Health Center Agreements	8, 8	Health Center Agreements ,   Health Center Agreements Final
Health Center Controlled Networks Progress Report	40, 40	HCCN Progress Report (track changes) ,   HCCN Progress Report Final
Health Center Controlled Networks Work Plan	41, 41	HCCN Work Plan (track changes) ,   HCCN Work Plan 2016 Cohort.pdf
Implementation Plan	19, 19	Implementation Plan (track changes) ,   Implementation plan 2017 Final
Income Analysis	3, 3, 3A, 3A	Income Analysis ,   Income Analysis Final ,   Look alike Budget ,   Look Alike Budget Information Final
Look Alike Budget	1	Look Alike Budget
Need for Assitance Worksheet	9, 9	Need for Assistance Worksheet ,   Need for Assistance Worksheet Final
O & E Progress Report	28, 28	OE Progress_Report (track changes) ,   OE Progress_Report 2017 Final
O & E Supplemental	27, 27	Outreach and Enrollment Supplemental form (track changes).docx ,   Outreach and Enrollment Supplemental 2017 Final
Organization Contacts	12, 12	Organization Contacts ,   Organization Contacts Final
Other Activities/Locations	5C, 5C	Other Activities/Locations ,   Other Activities/Locations Final
Other Requirements for Sites	24, 24	Other requirement for sites (track changes) ,   Other requirement for sites 2017 Final
Program Narrative Update	38	Program Narrative Update 2017
Project Cover Page	22	Project Cover Page (track changes)
Project Qualification Criteria	26, 26	Project Qualification Criteria (track changes) ,   Project Qualification Criteria 2017 Final
Project Work Plan	20, 20	Project Work Plan (track changes) ,   Project Work Plan Final
Proposal Cover Page	21, 21	Proposal Cover Page (track changes) ,   Proposal Cover Page 2017 Final
Request for Waiver of Governance Requirements	6B, 6B	Request for Waiver of Board Member ,   Request for Waiver of Board Member Final
Service Sites	5B	Service Sites
Services Provided	5A, 5A	Services Provided ,   Services Provided Final
Staffing Profile	2, 2	Staffing Profile ,   Staffing Profile Final
Substance Abuse Progress Report	39	Substance Abuse Progress Report
Summary Page	37	Summary Page 2017.docx
Supplemental Information	36	Supplemental 2017.docx
Verification Checklist	1	Verification Checklist
Zika Progress Report	42	Zika Progress Report.pdf

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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	35,566	32,450	0	4,166	-1,050	0
Annual Time Burden (Hours)	44,608	44,825	0	1,408	-1,625	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: The use of information technology has reduced the burden in some forms used in this ICR. Burden increases are due to more information needed from respondents.

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Annual Cost to Federal Government: $171,586

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: 08/16/2016

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