Information Collection Request

The Health Center Program Application Forms

ICR 202301-0915-005 · OMB 0915-0285 · Received in OIRA

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0915-0285 can be found here:

Forms and Documents

Document	Type	Status	Availability
Form 1 Capital Semi-Annual Progress Report	Form and Instruction	Removed	Repair queued
Form 15 Funding Request Summary Form (SBHC)	Form and Instruction	New	Repair queued
Form 13 Applicant Qualification Criteria Form	Form and Instruction	New	Repair queued
Form 9a Capital Semi Annual Progress Report	Form and Instruction	New	Repair queued
Form 13 FY 2022 Accelerating Cancer Screening Progress Report	Form and Instruction	New	Repair queued
Form 11 QIF Evaluative Measures Report	Form and Instruction	New	Missing upstream
Form 12 Project Cover Page	Form and Instruction	New	Repair queued
Form 7a Progress Report Non-Capital Investment	Form and Instruction	New	Repair queued
Form 7a Patient Impact Form	Form and Instruction	New	Repair queued
Form 6a NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update	Form and Instruction	New	Repair queued
Form 4a NHHCIA NCC Financial Performance Measures	Form and Instruction	New	Repair queued
Form 3a NHHCIA NCC Clinical Performance Measures	Form and Instruction	New	Repair queued
Form 2a QIF Project Plan Form	Form and Instruction	New	Repair queued
Form 1a QIF Progress Report	Form and Instruction	New	Repair queued
Form 39 Program Specific Forms Instructions	Form and Instruction	Removed	Repair queued
Form 38 Patient Target and Calculations	Form and Instruction	Unchanged	Repair queued
Form 37 Participating Health Center List	Form and Instruction	Unchanged	Repair queued
Form 18 Form 3A: FQHC Look-Alike Budget Information	Form and Instruction	Unchanged	Repair queued
Form 13 Form 1A: General Information Worksheet	Form and Instruction	Unchanged	Missing upstream
Form 8 Diabetes Action Plan - Quarterly Report Template	Form and Instruction	Removed	Repair queued
Form 34 HRSA Loan Guarantee Program Application	Form and Instruction	Unchanged	Missing upstream
Form 10a Health Center Controlled Networks (HCCN) Progress Report Table	Form and Instruction	Modified	Missing upstream
Form 31 Health Center Program Progress Report	Form and Instruction	Unchanged	Missing upstream
Form 40 Project Narrative Update	Form and Instruction	Modified	Repair queued
Form 46 Summary Page	Form and Instruction	Modified	Repair queued
Form 11 Federal Object Class Categories	Form and Instruction	Unchanged	Repair queued
Form 29 FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting	Form and Instruction	Unchanged	Repair queued
Form 28 FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting	Form and Instruction	Removed	Repair queued
Form 32 Health Center Program: Supplemental Information	Form and Instruction	Removed	Repair queued
Form 44 Project Work Plan	Form and Instruction	Unchanged	Repair queued
Form 35 Operational Plan	Form and Instruction	Unchanged	Missing upstream
Form 43 Project Qualification Criteria	Form and Instruction	Modified	Repair queued
Form 27 Funding Sources	Form and Instruction	Unchanged	Repair queued
Form 10 Expanded Services	Form and Instruction	Unchanged	Repair queued
Form 4 Checklist for Adding a New Target Population	Form and Instruction	Unchanged	Repair queued
Form 36 Other Requirements for Sites	Form and Instruction	Unchanged	Repair queued
Form 9 Equipment List	Form and Instruction	Modified	Repair queued
Form 41 Project Overview	Form and Instruction	Modified	Repair queued
Form 45 Proposal Cover Page	Form and Instruction	Unchanged	Repair queued
Form 6 Checklist for Deleting Existing Service Delivery Site	Form and Instruction	Unchanged	Repair queued
Form 3 Checklist for Adding a new Service Delivery Site	Form and Instruction	Unchanged	Missing upstream
Form 5 Checklist for Deleting Existing Service	Form and Instruction	Unchanged	Repair queued
Form 2 Checklist for Adding New Service	Form and Instruction	Unchanged	Repair queued
Form 12 Financial Performance Indicators	Form and Instruction	Modified	Repair queued
Form 26 Form 12: Organization Contacts	Form and Instruction	Modified	Repair queued
Form 7 Clinical Performance Measures	Form and Instruction	Removed	Repair queued
Form 33 HRSA EHBs Action Plan	Form and Instruction	Removed	Repair queued
Form 42 Project Plan	Form and Instruction	Modified	Repair queued
Form 25 Form 8: Health Center Agreements	Form and Instruction	Modified	Repair queued
Form 24 Form 6B: Request for Waiver of Governance Requirements	Form and Instruction	Unchanged	Repair queued
Form 23 Form 6A: Current Board Member Characteristics	Form and Instruction	Modified	Repair queued
Form 22 Form 5C: Other Activities/Locations	Form and Instruction	Modified	Repair queued
Form 21 Form 5B: Service Sites	Form and Instruction	Modified	Repair queued
Form 20 Form 5A: Services Provided	Form and Instruction	Modified	Repair queued
Form 19 Form 4: Community Characteristics	Form and Instruction	Modified	Repair queued
Form 17E Form 3: Income Analysis	Form and Instruction	Modified	Repair queued
Form 16 Form 2: Staffing Profile	Form and Instruction	Modified	Repair queued
Form 15 Form 1C: Documents on File	Form and Instruction	Modified	Missing upstream
Form 14 Form 1B: BPHC Funding Request Summary	Form and Instruction	Modified	Missing upstream
FY23 Supporting Statement Final Edited.docx	Supporting Statement A	Uploaded 2023-02-07	Repair queued

IC Document Collections

IC ID	Collection	Type	Status
6538	Capital Semi-Annual Progress Report	Form and Instruction	Removed
258364	Funding Request Summary Form (SBHC)	Form and Instruction	New
258356	Applicant Qualification Criteria Form	Form and Instruction	New
258281	Capital Semi Annual Progress Report	Form and Instruction	New
258277	FY 2022 Accelerating Cancer Screening Progress Report	Form and Instruction	New
258276	QIF Evaluative Measures Report	Form and Instruction	New
258275	Project Cover Page	Form and Instruction	New
258274	Progress Report Non-Capital Investment	Form and Instruction	New
258272	Patient Impact Form	Form and Instruction	New
258270	NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update	Form and Instruction	New
258269	NHHCIA NCC Financial Performance Measures	Form and Instruction	New
258267	NHHCIA NCC Clinical Performance Measures	Form and Instruction	New
258266	QIF Project Plan Form	Form and Instruction	New
258265	QIF Progress Report	Form and Instruction	New
239183	Program Specific Forms Instructions	Form and Instruction	Removed
239182	Patient Target and Calculations	Form and Instruction	Unchanged
239181	Participating Health Center List	Form and Instruction	Unchanged
239173	Form 3A: FQHC Look-Alike Budget Information	Form and Instruction	Unchanged
239164	Form 1A: General Information Worksheet	Form and Instruction	Unchanged
223047	Diabetes Action Plan - Quarterly Report Template	Form and Instruction	Removed
223046	HRSA Loan Guarantee Program Application	Form and Instruction	Unchanged
223045	Health Center Controlled Networks (HCCN) Progress Report Table	Form and Instruction	Modified
223043	Health Center Program Progress Report	Form and Instruction	Unchanged
223042	Project Narrative Update	Form and Instruction	Modified
223041	Summary Page	Form and Instruction	Modified
223040	Federal Object Class Categories	Form and Instruction	Unchanged
207854	FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting	Form and Instruction	Unchanged
207853	FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting	Form and Instruction	Removed
207852	Health Center Program: Supplemental Information	Form and Instruction	Removed
207848	Project Work Plan	Form and Instruction	Unchanged
207847	Operational Plan	Form and Instruction	Unchanged
207846	Project Qualification Criteria	Form and Instruction	Modified
207845	Funding Sources	Form and Instruction	Unchanged
207844	Expanded Services	Form and Instruction	Unchanged
207843	Checklist for Adding a New Target Population	Form and Instruction	Unchanged
193532	Other Requirements for Sites	Form and Instruction	Unchanged
193531	Equipment List	Form and Instruction	Modified
193528	Project Overview	Form and Instruction	Modified
193527	Proposal Cover Page	Form and Instruction	Unchanged
193526	Checklist for Deleting Existing Service Delivery Site	Form and Instruction	Unchanged
193525	Checklist for Adding a new Service Delivery Site	Form and Instruction	Unchanged
193523	Checklist for Deleting Existing Service	Form and Instruction	Unchanged
193522	Checklist for Adding New Service	Form and Instruction	Unchanged
193520	Financial Performance Indicators	Form and Instruction	Modified
180786	Form 12: Organization Contacts	Form and Instruction	Modified
180785	Clinical Performance Measures	Form and Instruction	Removed
180784	HRSA EHBs Action Plan	Form and Instruction	Removed
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	Unchanged
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

Status	Received in OIRA
Agency/Subagency	HHS/HSA
OMB Control No	0915-0285
Type of Information Collection	Revision of a currently approved collection
Previous ICR Reference No	202011-0915-002
Agency Tracking No	21063
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31