Application for Federally Supported Health Centers Assistance Act (FSHCAA) / Federal Tort Claims Act (FTCA) Particularized Determination of Coverage

Forms and Documents

Document Name	Status
Form 1 FTCA Particularized Determination Application Form and Instruction	New
Particularized Determination Application Supporting Statement BPHC REV 1.docx Supporting Statement A	2023-07-12

IC Document Collections

IC ID	Document Title	Status
261049	FTCA Particularized Determination Application Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202307-0906-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Application for Federally Supported Health Centers Assistance Act (FSHCAA) / Federal Tort Claims Act (FTCA) Particularized Determination of Coverage
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/14/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	12	0
Time Burden (Hours)	24	0
Cost Burden (Dollars)	0	0

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Abstract: The FTCA Program uses a web-based application system within HRSA’s Electronic Handbooks (EHBs) system for deeming applications. These electronic application forms decrease the time and effort required to complete the older, paper-based approved deeming application forms. HRSA is proposing a new paper application that will be transitioned into an electronic application within the EHB system for Particularized Determinations (PD). PDs extend liability protections under FSCHAA, including FTCA coverage, for certain medical services provided to individuals who are not patients of a covered entity. This application will help ensure health centers provide all the necessary information required to make determinations appropriately and efficiently in response to their requests. By including the application within the EHBs, health centers will have access to all information from prior applications and have that information readily available if making future requests. The paper form of the application is an interim solution to support health centers until the electronic application becomes available in the FTCA module of the EHBs. After the electronic application is available in the EHBs, all PD requests will be submitted electronically, and the paper application will no longer be used for submissions.

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Authorizing Statute(s): None

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:
	88 FR 14377	03/08/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 42085	06/29/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
FTCA Particularized Determination Application	1	FTCA Particularized Determination Application

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ICR Summary of Burden

	Total Request	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	12	0	0	12	0	0
Annual Time Burden (Hours)	24	0	0	24	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: This is a new package.

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Annual Cost to Federal Government: $189,138

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? No

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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: 07/14/2023

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