Funding Request Summary

The Health Center Program Application Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0285 can be found here:

Documents and Forms

Document Name Document Type
Form 1B Funding Request Summary Form
1B BPHC Funding Request Summary Form 1B (track changes).docx Form
1B BPHC Funding Request Summary Final Form 1B - 2017.docx Form

Information Collection (IC) Details

IC Title:	Funding Request Summary	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1B	BPHC Funding Request Summary	Form 1B (track changes).docx		Yes	Yes	Fillable Fileable
Form	1B	BPHC Funding Request Summary Final	Form 1B - 2017.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 450	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	450	50	400
Annual IC Time Burden (Hours)	338	-62	400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.