The Health Center Program Application Forms

Forms and Documents

Document Name	Status
Form 15 Funding Request Summary Form (SBHC) Form and Instruction	Unchanged
Form 13 Applicant Qualification Criteria Form Form and Instruction	Unchanged
Form 9a Capital Semi Annual Progress Report Form and Instruction	Unchanged
Form 13 FY 2022 Accelerating Cancer Screening Progress Report Form and Instruction	Unchanged
Form 11 QIF Evaluative Measures Report Form and Instruction	Unchanged
Form 12 Project Cover Page Form and Instruction	Unchanged
Form 7a Progress Report Non-Capital Investment Form and Instruction	Unchanged
Form 7a Patient Impact Form Form and Instruction	Unchanged
Form 6a NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update Form and Instruction	Unchanged
Form 4a NHHCIA NCC Financial Performance Measures Form and Instruction	Unchanged
Form 3a NHHCIA NCC Clinical Performance Measures Form and Instruction	Unchanged
Form 2a QIF Project Plan Form Form and Instruction	Unchanged
Form 1a QIF Progress Report Form and Instruction	Modified
Form 38 Patient Target and Calculations Form and Instruction	Unchanged
Form 37 Participating Health Center List Form and Instruction	Unchanged
Form 18 Form 3A: FQHC Look-Alike Budget Information Form and Instruction	Unchanged
Form 13 Form 1A: General Information Worksheet Form and Instruction	Unchanged
Form 34 HRSA Loan Guarantee Program Application Form and Instruction	Unchanged
Form 10a Health Center Controlled Networks (HCCN) Progress Report Table Form and Instruction	Unchanged
Form 31 Health Center Program Progress Report Form and Instruction	Unchanged
Form 40 Project Narrative Update Form and Instruction	Unchanged
Form 46 Summary Page Form and Instruction	Unchanged
Form 11 Federal Object Class Categories Form and Instruction	Unchanged
Form 29 FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Form and Instruction	Unchanged
Form 44 Project Work Plan Form and Instruction	Unchanged
Form 35 Operational Plan Form and Instruction	Unchanged
Form 43 Project Qualification Criteria Form and Instruction	Unchanged
Form 27 Funding Sources Form and Instruction	Unchanged
Form 10 Expanded Services Form and Instruction	Unchanged
Form 4 Checklist for Adding a New Target Population Form and Instruction	Unchanged
Form 36 Other Requirements for Sites Form and Instruction	Unchanged
Form 9 Equipment List Form and Instruction	Unchanged
Form 41 Project Overview Form and Instruction	Unchanged
Form 45 Proposal Cover Page Form and Instruction	Unchanged
Form 6 Checklist for Deleting Existing Service Delivery Site Form and Instruction	Unchanged
Form 3 Checklist for Adding a new Service Delivery Site Form and Instruction	Unchanged
Form 5 Checklist for Deleting Existing Service Form and Instruction	Unchanged
Form 2 Checklist for Adding New Service Form and Instruction	Unchanged
Form 12 Financial Performance Indicators Form and Instruction	Unchanged
Form 26 Form 12: Organization Contacts Form and Instruction	Unchanged
Form 42 Project Plan Form and Instruction	Unchanged
Form 25 Form 8: Health Center Agreements Form and Instruction	Unchanged
Form 24 Form 6B: Request for Waiver of Governance Requirements Form and Instruction	Unchanged
Form 23 Form 6A: Current Board Member Characteristics Form and Instruction	Unchanged
Form 22 Form 5C: Other Activities/Locations Form and Instruction	Unchanged
Form 21 Form 5B: Service Sites Form and Instruction	Unchanged
Form 20 Form 5A: Services Provided Form and Instruction	Unchanged
Form 19 Form 4: Community Characteristics Form and Instruction	Unchanged
Form 17E Form 3: Income Analysis Form and Instruction	Unchanged
Form 16 Form 2: Staffing Profile Form and Instruction	Unchanged
Form 15 Form 1C: Documents on File Form and Instruction	Unchanged
Form 14 Form 1B: BPHC Funding Request Summary Form and Instruction	Unchanged
QIF TJI OMB NonSubstantive Change Request__11_20_2024_V3 (2).docx Justification for No Material/Nonsubstantive Change	2024-11-26
FY23 Supporting Statement Final Edited.docx Supporting Statement A	2023-02-07

IC Document Collections

IC ID	Document Title	Status
258364	Funding Request Summary Form (SBHC) Form and Instruction	Unchanged
258356	Applicant Qualification Criteria Form Form and Instruction	Unchanged
258281	Capital Semi Annual Progress Report Form and Instruction	Unchanged
258277	FY 2022 Accelerating Cancer Screening Progress Report Form and Instruction	Unchanged
258276	QIF Evaluative Measures Report Form and Instruction	Unchanged
258275	Project Cover Page Form and Instruction	Unchanged
258274	Progress Report Non-Capital Investment Form and Instruction	Unchanged
258272	Patient Impact Form Form and Instruction	Unchanged
258270	NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update Form and Instruction	Unchanged
258269	NHHCIA NCC Financial Performance Measures Form and Instruction	Unchanged
258267	NHHCIA NCC Clinical Performance Measures Form and Instruction	Unchanged
258266	QIF Project Plan Form Form and Instruction	Unchanged
258265	QIF Progress Report Form and Instruction	Modified
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
223046	HRSA Loan Guarantee Program Application Form and Instruction	Unchanged
223045	Health Center Controlled Networks (HCCN) Progress Report Table Form and Instruction	Unchanged
223043	Health Center Program Progress Report Form and Instruction	Unchanged
223042	Project Narrative Update Form and Instruction	Unchanged
223041	Summary Page Form and Instruction	Unchanged
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
207848	Project Work Plan Form and Instruction	Unchanged
207847	Operational Plan Form and Instruction	Unchanged
207846	Project Qualification Criteria Form and Instruction	Unchanged
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	Unchanged
193528	Project Overview Form and Instruction	Unchanged
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	Unchanged
180786	Form 12: Organization Contacts Form and Instruction	Unchanged
180783	Project Plan Form and Instruction	Unchanged
180781	Form 8: Health Center Agreements Form and Instruction	Unchanged
180780	Form 6B: Request for Waiver of Governance Requirements Form and Instruction	Unchanged
180779	Form 6A: Current Board Member Characteristics Form and Instruction	Unchanged
180778	Form 5C: Other Activities/Locations Form and Instruction	Unchanged
180777	Form 5B: Service Sites Form and Instruction	Unchanged
180776	Form 5A: Services Provided Form and Instruction	Unchanged
180775	Form 4: Community Characteristics Form and Instruction	Unchanged
180774	Form 3: Income Analysis Form and Instruction	Unchanged
180773	Form 2: Staffing Profile Form and Instruction	Unchanged
180772	Form 1C: Documents on File Form and Instruction	Unchanged
180771	Form 1B: BPHC Funding Request Summary Form and Instruction	Unchanged

ICR Details

OMB Control No: 0915-0285	ICR Reference No: 202411-0915-001
Status: Received in OIRA	Previous ICR Reference No: 202301-0915-005
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	Date Submitted to OIRA: 11/26/2024

	Requested	Previously Approved
Expiration Date	04/30/2026	04/30/2026
Responses	39,279	39,279
Time Burden (Hours)	46,529	46,529
Cost Burden (Dollars)	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:
	87 FR 62861	10/17/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 6284	01/31/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 52

IC Title	Form No.	Form Name
Applicant Qualification Criteria Form	13	Applicant Qualification Criteria Form
Capital Semi Annual Progress Report	9a	Capital Semi Annual Progress Report
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
Equipment List	9	Equipment List
Expanded Services	10, 10E	Expanded Services Clean.docx ,   Expanded Services - edits.docx
FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting	29, 29	FY2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting.docx ,   Progress Report PCHP Mark Up_add new report 10.30.20.docx
FY 2022 Accelerating Cancer Screening Progress Report	13	FY 2022 Accelerating Cancer Screening Progress Report
Federal Object Class Categories	11	Federal Object Class Category Form- clean.docx
Financial Performance Indicators	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 Request Summary Form (SBHC)	15	Funding Request Summary Form
Funding Sources	27	Funding Sources - clean.docx
HRSA Loan Guarantee Program Application	34	HRSA Loan Guarantee Program Application.docx
Health Center Controlled Networks (HCCN) Progress Report Table	10a	HCCN Progress Report
Health Center Program Progress Report	31, 31E	Health Center Program Progress Report - Clean.docx ,   Health Center Program Progress Report - edits.docx
NHHCIA NCC Clinical Performance Measures	3a	NHHCIA NCC Clinical Performance Measures
NHHCIA NCC Financial Performance Measures	4a	NHHCIA NCC Financial Performance Measures
NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update	6b, 6c, 6a	NHHCIA NCC Income Analysis Form ,   NHHCIA NCC Project Work Plan Progress Report ,   NHHCIA NCC Project Work Plan Update
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 Impact Form	7a	Patient Impact Form
Patient Target and Calculations	38	Patient Target and Calculation.docx
Progress Report Non-Capital Investment	7a	Progress Report- Non-Capital Investments
Project Cover Page	12	Proposal Cover Page
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
QIF Evaluative Measures Report	11	QIF Evaluative Measures Report
QIF Progress Report	1a, 1a_Revised Clean, 1a_Redline	QIF Progress Report ,   QIF TJI Progress Report ,   QIF TJI Progress Report Redline
QIF Project Plan Form	2a	QIF Project Plan Form
Summary Page	46, 46E	Summary Page - clean.docx ,   Summary Page - edits.docx

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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	39,279	39,279	0	0	0	0
Annual Time Burden (Hours)	46,529	46,529	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: 11/26/2024

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