Free Clinics FTCA Program Application

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Free Clinics FTCA Program Application	Form and Instruction	Modified	Available
CY 2019 Free Clinic Program application markup 06_22_18.docx	Supplementary Document	Uploaded 2018-07-30	Available
CY 19 Application _OMB non-substantive change memo_6_22_18 sd.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2018-07-27	Available
0293 Privacy Impact Assessment.pdf	Supplementary Document	Uploaded 2017-10-25	Available
0293 Supporting Statement 09.14.17 (clean).docx	Supporting Statement A	Uploaded 2017-10-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6548	Free Clinics FTCA Program Application	Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0293	ICR Reference No: 201807-0915-002
Status: Historical Active	Previous ICR Reference No: 201709-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Free Clinics FTCA Program Application
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 with change	Conclusion Date: 07/31/2018
	Date Received in OIRA: 07/27/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2020	11/30/2020	11/30/2020
Responses	684	0	684
Time Burden (Hours)	1,368	0	1,368
Cost Burden (Dollars)	0	0	0

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Abstract: Deemed status for FTCA medical malpractice coverage requires HRSA approval of an application for deeming of certain eligible individuals from a sponsoring Free Clinic. The FTCA Program Deeming Application for Free Clinics is an electronic application submitted to HRSA through the Electronic Handbooks as part of the process of deeming qualified health care professionals, board members, officers, and individual contractors.

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Authorizing Statute(s): 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:
	82 FR 28667	06/23/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 46511	10/05/2017
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Free Clinics FTCA Program Application	1	CY 2019 Free Clinic Program application CLEAN.docx

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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	684	684	0	0	0	0
Annual Time Burden (Hours)	1,368	1,368	0	0	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: $126,117

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 07/27/2018

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