The Health Center Program Application Forms

Forms and Documents

Document Name	Status
Form 1 Capital Semi-Annual Progress Report Form and Instruction	Modified
Form 39 Program Specific Forms Instructions Form and Instruction	New
Form 38 Patient Target and Calculations Form and Instruction	New
Form 37 Participating Health Center List Form and Instruction	New
Form 18 Form 3A: FQHC Look-Alike Budget Information Form and Instruction	New
Form 13 Form 1A: General Information Worksheet Form and Instruction	New
Form 8 Diabetes Action Plan - Quarterly Report Template Form and Instruction	Modified
Form 34 HRSA Loan Guarantee Program Application Form and Instruction	Modified
Form 30 Health Center Controlled Networks (HCCN) Progress Report Table Form and Instruction	Modified
Form 31 Health Center Program Progress Report Form and Instruction	Modified
Form 40 Project Narrative Update Form and Instruction	Modified
Form 46 Summary Page Form and Instruction	Modified
Form 11 Federal Object Class Categories Form and Instruction	Modified
Form 29 FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Form and Instruction	Modified
Form 28 FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting Form and Instruction	Modified
Form 32 Health Center Program: Supplemental Information Form and Instruction	Modified
Form 44 Project Work Plan Form and Instruction	Modified
Form 35 Operational Plan Form and Instruction	Modified
Form 43 Project Qualification Criteria Form and Instruction	Modified
Form 27 Funding Sources Form and Instruction	Modified
Form 10 Expanded Services Form and Instruction	Modified
Form 4 Checklist for Adding a New Target Population Form and Instruction	Modified
Form 36 Other Requirements for Sites Form and Instruction	Modified
Form 9 Equipment List Form and Instruction	Modified
Form 41 Project Overview Form and Instruction	Modified
Form 45 Proposal Cover Page Form and Instruction	Modified
Form 6 Checklist for Deleting Existing Service Delivery Site Form and Instruction	Modified
Form 3 Checklist for Adding a new Service Delivery Site Form and Instruction	Modified
Form 5 Checklist for Deleting Existing Service Form and Instruction	Modified
Form 2 Checklist for Adding New Service Form and Instruction	Modified
Form 12 Financial Performance Measures Form and Instruction	Modified
Form 26E Form 12: Organization Contacts Form and Instruction	Modified
Form 7 Clinical Performance Measures Form and Instruction	Modified
Form 33 HRSA EHBs Action Plan Form and Instruction	Modified
Form 42 Project Plan Form and Instruction	Modified
Form 25 Form 8: Health Center Agreements Form and Instruction	Modified
Form 24 Form 6B: Request for Waiver of Governance Requirements Form and Instruction	Modified
Form 23 Form 6A: Current Board Member Characteristics Form and Instruction	Modified
Form 22 Form 5C: Other Activities/Locations Form and Instruction	Modified
Form 21 Form 5B: Service Sites Form and Instruction	Modified
Form 20 Form 5A: Services Provided Form and Instruction	Modified
Form 19 Form 4: Community Characteristics Form and Instruction	Modified
Form 17E Form 3: Income Analysis Form and Instruction	Modified
Form 16 Form 2: Staffing Profile Form and Instruction	Modified
Form 15 Form 1C: Documents on File Form and Instruction	Modified
Form 14 Form 1B: BPHC Funding Request Summary Form and Instruction	Modified
Supporting Statement FINAL-Revised w TC 2-26-20_.docx Supporting Statement A	2020-03-11

IC Document Collections

IC ID	Document Title	Status
6538	Capital Semi-Annual Progress Report Form and Instruction	Modified
239183	Program Specific Forms Instructions Form and Instruction	New
239182	Patient Target and Calculations Form and Instruction	New
239181	Participating Health Center List Form and Instruction	New
239173	Form 3A: FQHC Look-Alike Budget Information Form and Instruction	New
239164	Form 1A: General Information Worksheet Form and Instruction	New
223047	Diabetes Action Plan - Quarterly Report Template Form and Instruction	Modified
223046	HRSA Loan Guarantee Program Application Form and Instruction	Modified
223045	Health Center Controlled Networks (HCCN) Progress Report Table Form and Instruction	Modified
223043	Health Center Program Progress Report Form and Instruction	Modified
223042	Project Narrative Update Form and Instruction	Modified
223041	Summary Page Form and Instruction	Modified
223040	Federal Object Class Categories Form and Instruction	Modified
207854	FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Form and Instruction	Modified
207853	FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting Form and Instruction	Modified
207852	Health Center Program: Supplemental Information Form and Instruction	Modified
207848	Project Work Plan Form and Instruction	Modified
207847	Operational Plan Form and Instruction	Modified
207846	Project Qualification Criteria Form and Instruction	Modified
207845	Funding Sources Form and Instruction	Modified
207844	Expanded Services Form and Instruction	Modified
207843	Checklist for Adding a New Target Population Form and Instruction	Modified
193532	Other Requirements for Sites Form and Instruction	Modified
193531	Equipment List Form and Instruction	Modified
193528	Project Overview Form and Instruction	Modified
193527	Proposal Cover Page Form and Instruction	Modified
193526	Checklist for Deleting Existing Service Delivery Site Form and Instruction	Modified
193525	Checklist for Adding a new Service Delivery Site Form and Instruction	Modified
193523	Checklist for Deleting Existing Service Form and Instruction	Modified
193522	Checklist for Adding New Service Form and Instruction	Modified
193520	Financial Performance Measures Form and Instruction	Modified
180786	Form 12: Organization Contacts Form and Instruction	Modified
180785	Clinical Performance Measures Form and Instruction	Modified
180784	HRSA EHBs Action Plan Form and Instruction	Modified
180783	Project Plan Form and Instruction	Modified
180781	Form 8: Health Center Agreements Form and Instruction	Modified
180780	Form 6B: Request for Waiver of Governance Requirements Form and Instruction	Modified
180779	Form 6A: Current Board Member Characteristics Form and Instruction	Modified
180778	Form 5C: Other Activities/Locations Form and Instruction	Modified
180777	Form 5B: Service Sites Form and Instruction	Modified
180776	Form 5A: Services Provided Form and Instruction	Modified
180775	Form 4: Community Characteristics Form and Instruction	Modified
180774	Form 3: Income Analysis Form and Instruction	Modified
180773	Form 2: Staffing Profile Form and Instruction	Modified
180772	Form 1C: Documents on File Form and Instruction	Modified
180771	Form 1B: BPHC Funding Request Summary Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0285	ICR Reference No: 202001-0915-001
Status: Historical Active	Previous ICR Reference No: 201608-0915-003
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: 03/17/2020
	Date Received in OIRA: 01/09/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2023	36 Months From Approved	03/31/2020
Responses	48,063	0	35,566
Time Burden (Hours)	59,242	0	44,608
Cost Burden (Dollars)	0	0	0

---

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.

---

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

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 13937	04/08/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 71433	12/27/2019
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 46

IC Title	Form No.	Form Name
Form 8: Health Center Agreements	25, 25E	Form 8 - Clean.docx ,   Form 8 - edits.docx
Project Plan	42	Project Plan.docx
HRSA EHBs Action Plan	33	HRSA EHBs Action Plan.docx
Federal Object Class Categories	11	Federal Object Class Category Form- clean.docx
Summary Page	46, 46E	Summary Page - clean.docx ,   Summary Page - edits.docx
Form 1B: BPHC Funding Request Summary	14, 14E	Form 1B - clean.docx ,   Form 1B - edits.DOCX
Form 1C: Documents on File	15E, 15	Form 1C - clean.docx ,   Form 1C edits.docx
Form 2: Staffing Profile	16, 16E	Form 2 - clean.docx ,   Form 2 - edits.docx
Form 3: Income Analysis	17E, 17	Form 3 - edits.docx ,   Form 3 - clean.docx
Form 4: Community Characteristics	19, 19E	Form 4 - Clean.docx ,   Form 4 - edits.docx
Form 5A: Services Provided	20, 20E	Form 5A - clean.docx ,   Form 5A - edits.docx
FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting	28	FY2018 Expanding Access to Quality SUD-MH IBHS Progress Reporting.docx
FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting	29	FY2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting.docx
Capital Semi-Annual Progress Report	1	Capital Semi Annual Progress Report (SAPR).docx
Form 1A: General Information Worksheet	13, 13E	Form 1A - clean.docx ,   Form 1A - edits.docx
Checklist for Adding a New Target Population	4, 4E	Checklist for Adding a New Target Population - Clean.docx ,   Checklist for Adding a New Target Population edits.docx
Project Work Plan	44, 44E	Project Work Plan - clean.docx ,   Project Work Plan - edits.docx
Expanded Services	10, 10E	Expanded Services Clean.docx ,   Expanded Services - edits.docx
Funding Sources	27	Funding Sources - clean.docx
Project Qualification Criteria	43	Project Qualification Criteria.docx
Operational Plan	35, 35E	Operational Plan - clean.docx ,   Operational Plan - edits.docx
Health Center Program: Supplemental Information	32, 32E	Health Center Program Supplemental Information - Clean.docx ,   Health Center Program Supplemental Information - Clean.docx
Form 5B: Service Sites	21, 21E	Form 5B - clean.docx ,   Form 5B - edits.docx
Form 5C: Other Activities/Locations	22, 22E	Form 5C - Clean.docx ,   Form 5C - edits.docx
Form 6A: Current Board Member Characteristics	23, 23E	Form 6A - Clean.docx ,   Form 6A - edits.docx
Project Narrative Update	40, 40E	Project Narrative Update - clean.docx ,   Project Narrative Update - edits.docx
Health Center Program Progress Report	31, 31E	Health Center Program Progress Report - Clean.docx ,   Health Center Program Progress Report - edits.docx
Patient Target and Calculations	38	Patient Target and Calculation.docx
Program Specific Forms Instructions	39, 39E	Program Specific Form Instructions Clean.docx ,   Program Specific Form Instructions Edits.docx
Form 3A: FQHC Look-Alike Budget Information	18, 18E	Form 3A - clean.docx ,   Form 3A - edits.docx
Participating Health Center List	37	Participating Health Centers List.docx
Form 6B: Request for Waiver of Governance Requirements	24, 24E	Form 6B - Clean.docx ,   Form 6B - edits.docx
Health Center Controlled Networks (HCCN) Progress Report Table	30, 30E	HCCN Progress Report - clean.docx ,   HCCN Progress Report -edits.docx
Form 12: Organization Contacts	26, 26E	Form 12 - edits.docx ,   Form 12 - Clean.docx
Financial Performance Measures	12, 12E	Financial Performance Measures - clean.docx ,   Financial Performance Measures - edits.docx
HRSA Loan Guarantee Program Application	34	HRSA Loan Guarantee Program Application.docx
Diabetes Action Plan - Quarterly Report Template	8	Diabetes Action Plan Quarterly Report.docx
Clinical Performance Measures	7, 7E	Clinical Performance Measures Clean.docx ,   Clinical Performance Measures edits.docx
Checklist for Adding New Service	2, 2E	Checklist for Adding New Service -Clean.docx ,   Checklist for Adding New Service edits.docx
Checklist for Deleting Existing Service	5, 5E	Checklist for Deleting Existing Service -Clean.docx ,   Checklist for Deleting Existing Service - edits.docx
Checklist for Adding a new Service Delivery Site	3, 3E	Checklist for Adding a New Service Delivery Site - Clean.docx ,   Checklist for Adding a New Service Delivery Site edits.docx
Checklist for Deleting Existing Service Delivery Site	6E, 6	Checklist for Deleting Existing Service Delivery Site - Clean.docx ,   Checklist for Deleting Existing Service Delivery Site edits.docx
Proposal Cover Page	45	Proposal Cover Page.docx
Project Overview	41	Project Overview.docx
Equipment List	9	Equipment List
Other Requirements for Sites	36	Other Requirements for Sites

---

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	48,063	35,566	0	3,756	8,741	0
Annual Time Burden (Hours)	59,242	44,608	0	3,756	10,878	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: No

Burden Reduction Due to:

Short Statement: The increase in hours is due to program adjustments resulting from an increase in the number of health center organizations, as well as an increase in the number of new funding opportunities that required new data to be submitted by the applicants. The data needed for new funding opportunities could not be captured in forms previously approved A burden decrease results from a reduction in respondents and/or average burden per response time.

---

Annual Cost to Federal Government: $154,046

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.     No

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.     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

---

Common Form ICR:  No

---

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: 01/09/2020

---