The Health Center Program Application Forms

ICR 202005-0915-003

OMB: 0915-0285

Federal Form Document

Forms and Documents
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Justification for No Material/Nonsubstantive Change
2020-05-26
Supporting Statement A
2020-03-11
IC Document Collections
IC ID
Document
Title
Status
6538 Modified
239183 Unchanged
239182 Unchanged
239181 Unchanged
239173 Unchanged
239164 Unchanged
223047 Unchanged
223046 Unchanged
223045 Unchanged
223043 Unchanged
223042 Unchanged
223041 Unchanged
223040 Unchanged
207854 Unchanged
207853 Unchanged
207852 Unchanged
207848 Unchanged
207847 Unchanged
207846 Unchanged
207845 Unchanged
207844 Unchanged
207843 Unchanged
193532 Unchanged
193531 Unchanged
193528 Unchanged
193527 Unchanged
193526 Unchanged
193525 Unchanged
193523 Unchanged
193522 Unchanged
193520 Unchanged
180786 Unchanged
180785 Unchanged
180784 Unchanged
180783 Unchanged
180781 Unchanged
180780 Unchanged
180779 Unchanged
180778 Unchanged
180777 Unchanged
180776 Unchanged
180775 Unchanged
180774 Unchanged
180773 Unchanged
180772 Unchanged
180771 Unchanged
ICR Details
0915-0285 202005-0915-003
Historical Active 202001-0915-001
HHS/HSA 21063
The Health Center Program Application Forms
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved with change 06/02/2020
Retrieve Notice of Action (NOA) 05/26/2020
  Inventory as of this Action Requested Previously Approved
03/31/2023 03/31/2023 03/31/2023
48,063 0 48,063
59,242 0 59,242
0 0 0

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.

US Code: 42 USC 254b Section 330 Name of Law: Health Centers, Public Health Service Act, as amended
  
US Code: 42 USC 300, Section 1006[c] Name of Law: Public Health Service Act

Not associated with rulemaking

  84 FR 13937 04/08/2019
84 FR 71433 12/27/2019
No

46
IC Title Form No. Form Name
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 - edits.docx ,   Form 6B - Clean.docx
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 15, 15E 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
Form 5B: Service Sites 21, 21E Form 5B - clean.docx ,   Form 5B - edits.docx
Form 5C: Other Activities/Locations 22E, 22 Form 5C - Clean.docx ,   Form 5C - edits.docx
Form 6A: Current Board Member Characteristics 23, 23E Form 6A - edits.docx ,   Form 6A - Clean.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
Health Center Controlled Networks (HCCN) Progress Report Table 30, 30E HCCN Progress Report - clean.docx ,   HCCN Progress Report -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 edits.docx ,   Clinical Performance Measures Clean.docx
Form 12: Organization Contacts 26, 26E Form 12 - Clean.docx ,   Form 12 - edits.docx
Financial Performance Measures 12, 12E Financial Performance Measures - clean.docx ,   Financial 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
Equipment List 9 Equipment List
Other Requirements for Sites 36 Other Requirements for Sites
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
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
Project Work Plan 44, 44E Project Work Plan - clean.docx ,   Project Work Plan - edits.docx
Health Center Program: Supplemental Information 32, 32E Health Center Program Supplemental Information - Clean.docx ,   Health Center Program Supplemental Information - Clean.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, 2 Progress Report COVID Mark Up_5.26.20.pdf ,   Capital Semi Annual Progress Report (SAPR).docx
Form 1A: General Information Worksheet 13, 13E Form 1A - clean.docx ,   Form 1A - edits.docx
Project Overview 41 Project Overview.docx

  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 48,063 0 0 0 0
Annual Time Burden (Hours) 59,242 59,242 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$154,046
No
    No
    No
No
No
No
Yes
Elyana Bowman 301 443-3983 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/26/2020


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