Health Center COVID-19 Vaccine Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 5 PCAs Survey Tool Questions 7-21.pdf	Form and Instruction	New	Available
Form 5 Primary Care Associations (PCAs) Survey Tool Questions	Form and Instruction	New	Repair queued
Form 1 HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement 8-16-21.pdf	Form and Instruction	New	Available
Form 1 HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement	Form and Instruction	New	Repair queued
Form 4 ADDENDUM Health Center COVID-19 Vaccine Program	Form and Instruction	Modified	Available
Form 4 Addendum to COVID-19 Data Collection Survey Tool	Form and Instruction	Modified	Repair queued
Form 3 HC_Data_Collection_Tool_08_27_2021_Final.docx	Form and Instruction	Modified	Available
Form 3 COVID-19 Data Collection Survey Tool	Form and Instruction	Modified	Repair queued
Form 2 Health Center COVID-19 Vaccine Program Readiness Assessment 8-21	Form and Instruction	Modified	Available
Form 2 Readiness Assessment Tool	Form and Instruction	Modified	Repair queued
SUPPORTING STATEMENT - 0062 revision.docx	Supporting Statement A	Uploaded 2021-08-18	Repair queued
HRSA AADM to OIRA AA Memo_FINAL.pdf	Supplementary Document	Uploaded 2021-02-17	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
248938	Primary Care Associations (PCAs) Survey Tool Questions	Form and Instruction	New	PCAs Survey Tool Questions 7-21.pdf
248938	Primary Care Associations (PCAs) Survey Tool Questions	Form and Instruction	New
248937	HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement	Form and Instruction	New	HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement 8-16-21.pdf
248937	HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement	Form and Instruction	New
245831	Addendum to COVID-19 Data Collection Survey Tool	Form and Instruction	Modified	ADDENDUM Health Center COVID-19 Vaccine Program
245831	Addendum to COVID-19 Data Collection Survey Tool	Form and Instruction	Modified
245830	COVID-19 Data Collection Survey Tool	Form and Instruction	Modified	HC_Data_Collection_Tool_08_27_2021_Final.docx
245830	COVID-19 Data Collection Survey Tool	Form and Instruction	Modified
245829	Readiness Assessment Tool	Form and Instruction	Modified	Health Center COVID-19 Vaccine Program Readiness Assessment 8-21
245829	Readiness Assessment Tool	Form and Instruction	Modified
245829	Readiness Assessment Tool	Instruction	Modified

ICR Details

OMB Control No: 0906-0062	ICR Reference No: 202108-0906-001
Status: Historical Active	Previous ICR Reference No: 202102-0906-002
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Health Center COVID-19 Vaccine Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/23/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/19/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2024	36 Months From Approved	09/30/2021
Responses	136,590	0	134,708
Time Burden (Hours)	101,343	0	100,690
Cost Burden (Dollars)	0	0	0

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Abstract: The Health Resources and Services Administration (HRSA) is requesting a revision of a previous emergency package for two data collection tools critical for vaccine distribution to health centers for the Health Center COVID-19 Vaccine Program. The Readiness Assessment – a one-time tool to collect data on the readiness and interest of HRSA-funded health centers preliminarily identified by CDC and HRSA to receive a direct allocation of a limited supply of COVID-19 vaccines, and the weekly COVID-19 Data Collection Survey Tool with an Addendum for health centers participating in the Program are essential to help track vaccine needs and capacity for health center sites, as well as evaluate program implementation. Respondents are Health Centers and Health Center Look-Alikes who are essential in meeting White House goals of equitable vaccine distribution, given the special populations that they serve. HRSA funds 1,400 health centers operating 13,000 services delivery sites serving nearly 30 million people under the Health Center Program. These respondents will play a critical role in ensuring the White House goal to deliver 100 million vaccinations in the first 100 days of the new administration, with a focus on equity.

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Authorizing Statute(s): US Code: 42 USC 254b, Section 330 Name of Law: PHSA as amended
  

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:
	86 FR 21756	04/23/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 41974	08/04/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Addendum to COVID-19 Data Collection Survey Tool	4	ADDENDUM Health Center COVID-19 Vaccine Program
COVID-19 Data Collection Survey Tool	3	HC_Data_Collection_Tool_08_27_2021_Final.docx
HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement	1	HC COVID-19 Vaccine Prgrm Conditions of Participation Agreement 8-16-21.pdf
Primary Care Associations (PCAs) Survey Tool Questions	5	PCAs Survey Tool Questions 7-21.pdf
Readiness Assessment Tool	2	Health Center COVID-19 Vaccine Program Readiness Assessment 8-21

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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	136,590	134,708	0	1,882	0	0
Annual Time Burden (Hours)	101,343	100,690	0	653	0	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 burden increase is due to the addition of two new forms to this ICR revision as well as an increase in respondents for form #2.

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Annual Cost to Federal Government: $1,500,000

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: 08/19/2021

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