The Health Center Program Application Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 2 Progress Report COVID Mark Up_5.26.20.pdf	Form and Instruction	Modified	Available
Form 1 Capital Semi Annual Progress Report (SAPR).docx	Form and Instruction	Modified	Available
Form 39E Program Specific Form Instructions Edits.docx	Form and Instruction	Unchanged	Available
Form 39 Program Specific Form Instructions Clean.docx	Form and Instruction	Unchanged	Available
Form 38 Patient Target and Calculation.docx	Form and Instruction	Unchanged	Available
Form 37 Participating Health Centers List.docx	Form and Instruction	Unchanged	Available
Form 18E Form 3A - edits.docx	Form and Instruction	Unchanged	Available
Form 18 Form 3A - clean.docx	Form and Instruction	Unchanged	Available
Form 13E Form 1A - edits.docx	Form and Instruction	Unchanged	Available
Form 13 Form 1A - clean.docx	Form and Instruction	Unchanged	Available
Form 8 Diabetes Action Plan Quarterly Report.docx	Form and Instruction	Unchanged	Available
Form 34 HRSA Loan Guarantee Program Application.docx	Form and Instruction	Unchanged	Available
Form 30E HCCN Progress Report -edits.docx	Form and Instruction	Unchanged	Available
Form 30 HCCN Progress Report - clean.docx	Form and Instruction	Unchanged	Available
Form 31E Health Center Program Progress Report - edits.docx	Form and Instruction	Unchanged	Available
Form 31 Health Center Program Progress Report - Clean.docx	Form and Instruction	Unchanged	Available
Form 40E Project Narrative Update - edits.docx	Form and Instruction	Unchanged	Available
Form 40 Project Narrative Update - clean.docx	Form and Instruction	Unchanged	Available
Form 46E Summary Page - edits.docx	Form and Instruction	Unchanged	Available
Form 46 Summary Page - clean.docx	Form and Instruction	Unchanged	Available
Form 11 Federal Object Class Category Form- clean.docx	Form and Instruction	Unchanged	Available
Form 29 FY2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting.docx	Form and Instruction	Unchanged	Available
Form 28 FY2018 Expanding Access to Quality SUD-MH IBHS Progress Reporting.docx	Form and Instruction	Unchanged	Available
Form 32E Health Center Program Supplemental Information - Clean.docx	Form and Instruction	Unchanged	Available
Form 32 Health Center Program Supplemental Information - Clean.docx	Form and Instruction	Unchanged	Available
Form 44E Project Work Plan - edits.docx	Form and Instruction	Unchanged	Available
Form 44 Project Work Plan - clean.docx	Form and Instruction	Unchanged	Available
Form 35E Operational Plan - edits.docx	Form and Instruction	Unchanged	Available
Form 35 Operational Plan - clean.docx	Form and Instruction	Unchanged	Available
Form 43 Project Qualification Criteria.docx	Form and Instruction	Unchanged	Available
Form 27 Funding Sources - clean.docx	Form and Instruction	Unchanged	Available
Form 10E Expanded Services - edits.docx	Form and Instruction	Unchanged	Available
Form 10 Expanded Services Clean.docx	Form and Instruction	Unchanged	Available
Form 4E Checklist for Adding a New Target Population edits.docx	Form and Instruction	Unchanged	Available
Form 4 Checklist for Adding a New Target Population - Clean.docx	Form and Instruction	Unchanged	Available
Form 36 Other Requirements for Sites	Form and Instruction	Unchanged	Available
Form 9 Equipment List	Form and Instruction	Unchanged	Available
Form 41 Project Overview.docx	Form and Instruction	Unchanged	Available
Form 45 Proposal Cover Page.docx	Form and Instruction	Unchanged	Available
Form 6E Checklist for Deleting Existing Service Delivery Site edits.docx	Form and Instruction	Unchanged	Available
Form 6 Checklist for Deleting Existing Service Delivery Site - Clean.docx	Form and Instruction	Unchanged	Available
Form 3E Checklist for Adding a New Service Delivery Site edits.docx	Form and Instruction	Unchanged	Available
Form 3 Checklist for Adding a New Service Delivery Site - Clean.docx	Form and Instruction	Unchanged	Available
Form 5E Checklist for Deleting Existing Service - edits.docx	Form and Instruction	Unchanged	Available
Form 5 Checklist for Deleting Existing Service -Clean.docx	Form and Instruction	Unchanged	Available
Form 2E Checklist for Adding New Service edits.docx	Form and Instruction	Unchanged	Available
Form 2 Checklist for Adding New Service -Clean.docx	Form and Instruction	Unchanged	Repair queued
Form 12E Financial Performance Measures - edits.docx	Form and Instruction	Unchanged	Available
Form 12 Financial Performance Measures - clean.docx	Form and Instruction	Unchanged	Available
Form 26E Form 12 - edits.docx	Form and Instruction	Unchanged	Available
Form 26 Form 12 - Clean.docx	Form and Instruction	Unchanged	Available
Form 7E Clinical Performance Measures edits.docx	Form and Instruction	Unchanged	Available
Form 7 Clinical Performance Measures Clean.docx	Form and Instruction	Unchanged	Available
Form 33 HRSA EHBs Action Plan.docx	Form and Instruction	Unchanged	Available
Form 42 Project Plan.docx	Form and Instruction	Unchanged	Available
Form 25E Form 8 - edits.docx	Form and Instruction	Unchanged	Available
Form 25 Form 8 - Clean.docx	Form and Instruction	Unchanged	Available
Form 24E Form 6B - edits.docx	Form and Instruction	Unchanged	Available
Form 24 Form 6B - Clean.docx	Form and Instruction	Unchanged	Available
Form 23E Form 6A - edits.docx	Form and Instruction	Unchanged	Available
Form 23 Form 6A - Clean.docx	Form and Instruction	Unchanged	Available
Form 22E Form 5C - edits.docx	Form and Instruction	Unchanged	Available
Form 22 Form 5C - Clean.docx	Form and Instruction	Unchanged	Available
Form 21E Form 5B - edits.docx	Form and Instruction	Unchanged	Available
Form 21 Form 5B - clean.docx	Form and Instruction	Unchanged	Available
Form 20E Form 5A - edits.docx	Form and Instruction	Unchanged	Available
Form 20 Form 5A - clean.docx	Form and Instruction	Unchanged	Available
Form 19E Form 4 - edits.docx	Form and Instruction	Unchanged	Available
Form 19 Form 4 - Clean.docx	Form and Instruction	Unchanged	Available
Form 17 Form 3 - clean.docx	Form and Instruction	Unchanged	Available
Form 17E Form 3 - edits.docx	Form and Instruction	Unchanged	Available
Form 16E Form 2 - edits.docx	Form and Instruction	Unchanged	Available
Form 16 Form 2 - clean.docx	Form and Instruction	Unchanged	Available
Form 15E Form 1C edits.docx	Form and Instruction	Unchanged	Available
Form 15 Form 1C - clean.docx	Form and Instruction	Unchanged	Available
Form 14E Form 1B - edits.DOCX	Form and Instruction	Unchanged	Available
Form 14 Form 1B - clean.docx	Form and Instruction	Unchanged	Available
Change Memo - OMB PPR 2020_HRSA BPHC 5.26.20.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-05-26	Available
Supporting Statement FINAL-Revised w TC 2-26-20_.docx	Supporting Statement A	Uploaded 2020-03-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6538	Capital Semi-Annual Progress Report	Form and Instruction	Modified	Progress Report COVID Mark Up_5.26.20.pdf
6538	Capital Semi-Annual Progress Report	Form and Instruction	Modified	Capital Semi Annual Progress Report (SAPR).docx
239183	Program Specific Forms Instructions	Form and Instruction	Unchanged	Program Specific Form Instructions Edits.docx
239183	Program Specific Forms Instructions	Form and Instruction	Unchanged	Program Specific Form Instructions Clean.docx
239182	Patient Target and Calculations	Form and Instruction	Unchanged	Patient Target and Calculation.docx
239181	Participating Health Center List	Form and Instruction	Unchanged	Participating Health Centers List.docx
239173	Form 3A: FQHC Look-Alike Budget Information	Form and Instruction	Unchanged	Form 3A - edits.docx
239173	Form 3A: FQHC Look-Alike Budget Information	Form and Instruction	Unchanged	Form 3A - clean.docx
239164	Form 1A: General Information Worksheet	Form and Instruction	Unchanged	Form 1A - edits.docx
239164	Form 1A: General Information Worksheet	Form and Instruction	Unchanged	Form 1A - clean.docx
223047	Diabetes Action Plan - Quarterly Report Template	Form and Instruction	Unchanged	Diabetes Action Plan Quarterly Report.docx
223046	HRSA Loan Guarantee Program Application	Form and Instruction	Unchanged	HRSA Loan Guarantee Program Application.docx
223045	Health Center Controlled Networks (HCCN) Progress Report Table	Form and Instruction	Unchanged	HCCN Progress Report -edits.docx
223045	Health Center Controlled Networks (HCCN) Progress Report Table	Form and Instruction	Unchanged	HCCN Progress Report - clean.docx
223043	Health Center Program Progress Report	Form and Instruction	Unchanged	Health Center Program Progress Report - edits.docx
223043	Health Center Program Progress Report	Form and Instruction	Unchanged	Health Center Program Progress Report - Clean.docx
223042	Project Narrative Update	Form and Instruction	Unchanged	Project Narrative Update - edits.docx
223042	Project Narrative Update	Form and Instruction	Unchanged	Project Narrative Update - clean.docx
223041	Summary Page	Form and Instruction	Unchanged	Summary Page - edits.docx
223041	Summary Page	Form and Instruction	Unchanged	Summary Page - clean.docx
223040	Federal Object Class Categories	Form and Instruction	Unchanged	Federal Object Class Category Form- clean.docx
207854	FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting	Form and Instruction	Unchanged	FY2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting.docx
207853	FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting	Form and Instruction	Unchanged	FY2018 Expanding Access to Quality SUD-MH IBHS Progress Reporting.docx
207852	Health Center Program: Supplemental Information	Form and Instruction	Unchanged	Health Center Program Supplemental Information - Clean.docx
207852	Health Center Program: Supplemental Information	Form and Instruction	Unchanged	Health Center Program Supplemental Information - Clean.docx
207848	Project Work Plan	Form and Instruction	Unchanged	Project Work Plan - edits.docx
207848	Project Work Plan	Form and Instruction	Unchanged	Project Work Plan - clean.docx
207847	Operational Plan	Form and Instruction	Unchanged	Operational Plan - edits.docx
207847	Operational Plan	Form and Instruction	Unchanged	Operational Plan - clean.docx
207846	Project Qualification Criteria	Form and Instruction	Unchanged	Project Qualification Criteria.docx
207845	Funding Sources	Form and Instruction	Unchanged	Funding Sources - clean.docx
207844	Expanded Services	Form and Instruction	Unchanged	Expanded Services - edits.docx
207844	Expanded Services	Form and Instruction	Unchanged	Expanded Services Clean.docx
207843	Checklist for Adding a New Target Population	Form and Instruction	Unchanged	Checklist for Adding a New Target Population edits.docx
207843	Checklist for Adding a New Target Population	Form and Instruction	Unchanged	Checklist for Adding a New Target Population - Clean.docx
193532	Other Requirements for Sites	Form and Instruction	Unchanged	Other Requirements for Sites
193531	Equipment List	Form and Instruction	Unchanged	Equipment List
193528	Project Overview	Form and Instruction	Unchanged	Project Overview.docx
193527	Proposal Cover Page	Form and Instruction	Unchanged	Proposal Cover Page.docx
193526	Checklist for Deleting Existing Service Delivery Site	Form and Instruction	Unchanged	Checklist for Deleting Existing Service Delivery Site edits.docx
193526	Checklist for Deleting Existing Service Delivery Site	Form and Instruction	Unchanged	Checklist for Deleting Existing Service Delivery Site - Clean.docx
193525	Checklist for Adding a new Service Delivery Site	Form and Instruction	Unchanged	Checklist for Adding a New Service Delivery Site edits.docx
193525	Checklist for Adding a new Service Delivery Site	Form and Instruction	Unchanged	Checklist for Adding a New Service Delivery Site - Clean.docx
193523	Checklist for Deleting Existing Service	Form and Instruction	Unchanged	Checklist for Deleting Existing Service - edits.docx
193523	Checklist for Deleting Existing Service	Form and Instruction	Unchanged	Checklist for Deleting Existing Service -Clean.docx
193522	Checklist for Adding New Service	Form and Instruction	Unchanged	Checklist for Adding New Service edits.docx
193522	Checklist for Adding New Service	Form and Instruction	Unchanged	Checklist for Adding New Service -Clean.docx
193520	Financial Performance Measures	Form and Instruction	Unchanged	Financial Performance Measures - edits.docx
193520	Financial Performance Measures	Form and Instruction	Unchanged	Financial Performance Measures - clean.docx
180786	Form 12: Organization Contacts	Form and Instruction	Unchanged	Form 12 - edits.docx
180786	Form 12: Organization Contacts	Form and Instruction	Unchanged	Form 12 - Clean.docx
180785	Clinical Performance Measures	Form and Instruction	Unchanged	Clinical Performance Measures edits.docx
180785	Clinical Performance Measures	Form and Instruction	Unchanged	Clinical Performance Measures Clean.docx
180784	HRSA EHBs Action Plan	Form and Instruction	Unchanged	HRSA EHBs Action Plan.docx
180783	Project Plan	Form and Instruction	Unchanged	Project Plan.docx
180781	Form 8: Health Center Agreements	Form and Instruction	Unchanged	Form 8 - edits.docx
180781	Form 8: Health Center Agreements	Form and Instruction	Unchanged	Form 8 - Clean.docx
180780	Form 6B: Request for Waiver of Governance Requirements	Form and Instruction	Unchanged	Form 6B - edits.docx
180780	Form 6B: Request for Waiver of Governance Requirements	Form and Instruction	Unchanged	Form 6B - Clean.docx
180779	Form 6A: Current Board Member Characteristics	Form and Instruction	Unchanged	Form 6A - edits.docx
180779	Form 6A: Current Board Member Characteristics	Form and Instruction	Unchanged	Form 6A - Clean.docx
180778	Form 5C: Other Activities/Locations	Form and Instruction	Unchanged	Form 5C - edits.docx
180778	Form 5C: Other Activities/Locations	Form and Instruction	Unchanged	Form 5C - Clean.docx
180777	Form 5B: Service Sites	Form and Instruction	Unchanged	Form 5B - edits.docx
180777	Form 5B: Service Sites	Form and Instruction	Unchanged	Form 5B - clean.docx
180776	Form 5A: Services Provided	Form and Instruction	Unchanged	Form 5A - edits.docx
180776	Form 5A: Services Provided	Form and Instruction	Unchanged	Form 5A - clean.docx
180775	Form 4: Community Characteristics	Form and Instruction	Unchanged	Form 4 - edits.docx
180775	Form 4: Community Characteristics	Form and Instruction	Unchanged	Form 4 - Clean.docx
180774	Form 3: Income Analysis	Form and Instruction	Unchanged	Form 3 - clean.docx
180774	Form 3: Income Analysis	Form and Instruction	Unchanged	Form 3 - edits.docx
180773	Form 2: Staffing Profile	Form and Instruction	Unchanged	Form 2 - edits.docx
180773	Form 2: Staffing Profile	Form and Instruction	Unchanged	Form 2 - clean.docx
180772	Form 1C: Documents on File	Form and Instruction	Unchanged	Form 1C edits.docx
180772	Form 1C: Documents on File	Form and Instruction	Unchanged	Form 1C - clean.docx
180771	Form 1B: BPHC Funding Request Summary	Form and Instruction	Unchanged	Form 1B - edits.DOCX
180771	Form 1B: BPHC Funding Request Summary	Form and Instruction	Unchanged	Form 1B - clean.docx

ICR Details

OMB Control No: 0915-0285	ICR Reference No: 202005-0915-003
Status: Historical Active	Previous ICR Reference No: 202001-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No: 21063
Title: The Health Center Program Application Forms
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: 06/02/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/26/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2023	03/31/2023	03/31/2023
Responses	48,063	0	48,063
Time Burden (Hours)	59,242	0	59,242
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:
	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

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

table that charts list of burden

IC Title	Form No.	Form Name
Capital Semi-Annual Progress Report	1, 2	Capital Semi Annual Progress Report (SAPR).docx ,   Progress Report COVID Mark Up_5.26.20.pdf
Checklist for Adding New Service	2, 2E	Checklist for Adding New Service -Clean.docx ,   Checklist for Adding New Service 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
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	5, 5E	Checklist for Deleting Existing Service -Clean.docx ,   Checklist for Deleting Existing Service - 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
Clinical Performance Measures	7, 7E	Clinical Performance Measures Clean.docx ,   Clinical Performance Measures edits.docx
Diabetes Action Plan - Quarterly Report Template	8	Diabetes Action Plan Quarterly Report.docx
Equipment List	9	Equipment List
Expanded Services	10, 10E	Expanded Services Clean.docx ,   Expanded Services - 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
Federal Object Class Categories	11	Federal Object Class Category Form- clean.docx
Financial Performance Measures	12, 12E	Financial Performance Measures - clean.docx ,   Financial Performance Measures - edits.docx
Form 12: Organization Contacts	26, 26E	Form 12 - Clean.docx ,   Form 12 - edits.docx
Form 1A: General Information Worksheet	13, 13E	Form 1A - clean.docx ,   Form 1A - 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 3A: FQHC Look-Alike Budget Information	18, 18E	Form 3A - clean.docx ,   Form 3A - edits.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 - Clean.docx ,   Form 6A - edits.docx
Form 6B: Request for Waiver of Governance Requirements	24, 24E	Form 6B - Clean.docx ,   Form 6B - edits.docx
Form 8: Health Center Agreements	25, 25E	Form 8 - Clean.docx ,   Form 8 - edits.docx
Funding Sources	27	Funding Sources - clean.docx
HRSA EHBs Action Plan	33	HRSA EHBs Action Plan.docx
HRSA Loan Guarantee Program Application	34	HRSA Loan Guarantee Program Application.docx
Health Center Controlled Networks (HCCN) Progress Report Table	30, 30E	HCCN Progress Report - clean.docx ,   HCCN Progress Report -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 Program: Supplemental Information	32, 32E	Health Center Program Supplemental Information - Clean.docx ,   Health Center Program Supplemental Information - Clean.docx
Operational Plan	35, 35E	Operational Plan - clean.docx ,   Operational Plan - edits.docx
Other Requirements for Sites	36	Other Requirements for Sites
Participating Health Center List	37	Participating Health Centers List.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
Project Narrative Update	40, 40E	Project Narrative Update - clean.docx ,   Project Narrative Update - edits.docx
Project Overview	41	Project Overview.docx
Project Plan	42	Project Plan.docx
Project Qualification Criteria	43	Project Qualification Criteria.docx
Project Work Plan	44, 44E	Project Work Plan - clean.docx ,   Project Work Plan - edits.docx
Proposal Cover Page	45	Proposal Cover Page.docx
Summary Page	46, 46E	Summary Page - clean.docx ,   Summary Page - edits.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	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

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: $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? Yes

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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: 05/26/2020

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