Health Resources and Services Administration
SUPPORTING STATEMENT
The Health Center Program Forms
A. Justification
1. Circumstances of Information Collection
The Health Resources and Services Administration (HRSA) is requesting a revision of OMB approval for forms that are used by several Bureau of Primary Health Care (BPHC) programs providing grant funding to serve medically underserved and vulnerable populations. The forms are currently approved under OMB number 0915-0285, Health Center Program Application Forms with an expiration of March 31st, 2023.
The Health Center Program, administered by HRSA, is authorized under section 330 of the Public Health Service (PHS) Act, most recently amended by section 50901(b) of the Bipartisan Budget Act of 2018, P.L. 115-123. Health centers are community-based and patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients regardless of their ability to pay. Nearly 1,400 health centers operate approximately 12,000 service delivery sites that provide primary health care to more than 28 million people in every U.S. state, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Pacific Basin. HRSA utilizes forms for new and existing health centers and other entities to apply for various grant and non-grant opportunities, renew grant and non-grant designations, report progress, and change their scopes of project.
Health Center Program-specific forms are necessary for Health Center Program award processes and oversight. These forms provide HRSA staff and objective review committee panels with information essential for application evaluation, funding recommendation and approval, designation, and monitoring. These forms also provide HRSA staff with information essential for evaluating compliance with Health Center Program legislative and regulatory requirements.
2. Purpose and Use of the Information
The purpose of these forms is to provide information to HRSA staff and objective review committee panels to support application evaluation; funding recommendation and approval; designation; and monitoring. Health centers use a combination of the application forms to apply for one or more of the following opportunities:
Advancing Precision Medicine (APM) is a supplemental funding opportunity to support health center participation in the National Institutes of Health’s All of Us Research Program (AoU) and to advance health centers’ interoperability functionality, preparedness to use and share patient data, and capacity to participate in future research opportunities.
Budget Period Progress Report (BPR) is an application that provides an update on the progress for Health Center Program award recipients.
Capital Development funding opportunities provide funding for construction, renovation, repair and/or improvement of health center service delivery sites.
Change in Scope (CIS) requests are submitted by existing health centers to change the current approved scope of project as they relate to services offered, sites, and other scope activities that require prior approval by HRSA.
Health Center Controlled Networks (HCCNs) are networks of health centers working together to use health information technology (HIT) to improve operational and clinical practices.
Loan Guarantee Program (LGP) supports loans to eligible Health Center Program award recipients for the construction/expansion, alteration/renovation, and modernization of health center medical facilities.
Look-Alike (LAL) applications support organizations seeking initial designation, renewal of designation, or annual certification as a look-alike. Look-Alikes must meet all eligibility requirements of a section 330 grant, but they do not receive section 330 grant funds.
National Health Center Training and Technical Assistance Partners (NTTAPs) provide national training and technical assistance (T/TA) to potential and existing section 330-funded health centers with the goal of assisting them to address HHS and HRSA priorities, improve performance, and support program development and analysis activities.
Native Hawaiian Health Care Improvement Act (NHHCIA) is a congressional special initiative with the purpose of improving the provision of comprehensive disease prevention, health promotion, and primary care services to Native Hawaiians.
New Access Points (NAP) is a competitive funding opportunity that provides operational support for new service delivery sites for the provision of comprehensive primary health care services (i.e., new access points). Applicants must propose at least one full-time, permanent new access point site that has primary medical care as its main purpose.
Primary Care Associations (PCAs) are cooperative agreements with state and regional organizations that provide T/TA to potential and existing health centers with the goal of assisting them to address HHS and HRSA priorities, improve performance, and support program development and analysis activities.
Quality Improvement Fund (QIF) is a supplemental funding opportunity to support health centers to improve health outcomes and reduce racial and ethnic health disparities by partnering with patients and the community to develop and pilot innovative, patient-centered, scalable models of care delivery that address both the clinical and health-related social needs of health center patients.
Health Center Program School-Based Service Expansion (SBSE) provides funding to expand access to primary health care services through Health Center Program award recipients’ service delivery sites located at schools.
The School-Based Health Center (SBHC) program provides funding to increase access to high-quality, comprehensive primary health services for children and adolescents through school-based health centers.
Service Area Competition (SAC) is a competitive funding opportunity for existing and new health center organizations to receive federal financial assistance to support affordable, quality primary health care services for a community and its vulnerable population(s) in a service area already served by the Health Center Program.
The forms provide information that is required by HRSA for reviewing applications, award recommendations, monitoring, and ensuring compliance with conditions of award for the programs mentioned above. The following forms are used to collect the required information:
Capital Semi-Annual Progress Report: This form is used to monitor semi-annual activities to document progress for Capital funding.
Checklist for Adding a New Service: Combination of a checklist and narratives. It provides program with an understanding of the impact to the community and the population by the addition of the service(s).
Checklist for Adding a New Service Delivery Site: Combination of a checklist and narratives. It provides program with an understanding of the impact to the community and the population by the addition of the service site.
Checklist for Adding a New Target Population: Combination of a checklist and narratives. It provides program with an understanding of the impact to the community and the existing target population by the addition of the new target population.
Checklist for Deleting Existing Service: Combination of a checklist and narrative. It provides program with an understanding of the impact to the community and population by the deletion of the service(s).
Checklist for Deleting Existing Service Delivery Site: Combination of a checklist and narratives. It provides program with an understanding of the impact to the community and the population by the deletion of the service site.
Equipment List: Used by applicants to provide a detailed equipment list to identify the equipment to be purchased. Equipment type will be categorized as clinical or non-clinical.
Expanded Services Patient Impact Form (Previously Expanded Services Form): Collects the services and patient information for projects proposed in an Expanded Services supplemental application.
Federal Object Class Categories: Collects budget information that is not included on the SF-424A for future years.
Financial Performance Indicators (previously Financial Performance Measures): Collects information on specific financial performance measures to be accomplished during the project period, including goals; baselines; methodology; key contributing and restricting factors; and major planned actions.
Form 1A: General Information Worksheet: Collects summary information on the applicant organization and the proposed project including specific applicant information, the proposed service area, target population, service providers, and patient and visit projections.
Form 1B: BPHC Funding Request Summary: Collects program specific information about the use of federal funding.
Form 1C: Documents on File: Collects the date of the last review or revision of key documents used by the health center governing board and staff for ensuring compliance with Health Center Program requirements.
Form 2: Staffing Profile: Identifies the total personnel and number of full-time equivalents (FTEs) for the proposed project.
Form 3: Income Analysis: Identifies the estimated non-Federal revenues (all other sources of income aside from the section 330 grant funds) for the requested budget.
Form 3A: Look-Alike Budget Information: Collects projected expenses and revenues.
Form 4: Community Characteristics: Identifies service area and target population data.
Form 5A: Services Provided: Identifies the mode of service provision for all clinical and non-clinical services.
Form 5B: Service Sites: Collects information on the site location including address, contact information, and site characteristics (e.g., zip codes from which the majority of the patients will come to the site, hours of operation).
Form 5C: Other Activities/Locations: Collects information on activities provided at a location other than a service site.
Form 6A: Current Board Member Characteristics: Collects information on board members, including areas of expertise, years of service on the board, and demographics.
Form 6B: Request for Waiver of Board Member Requirements: Used to request a waiver of governing board requirements. Only organizations seeking support for Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care may request a waiver.
Form 8: Health Center Agreements: Identifies when the applicant organization has an agreement with another organization to carry out a substantial portion of the proposed scope of project and ensures compliance with governance requirements.
Form 12: Organization Contacts: Collects contact information for the Chief Executive Officer, Contact Person, Medical Director, and Dental Director of the organization.
Funding Sources: Identifies other sources of funding that will be necessary to fund the overall project proposal.
FY2020 Ending HIV Epidemic Primary Care HIV PCHP Progress Reporting: Collects quantifiable and annual progress toward funding goals.
HCCN Progress Report (previously HCCN Progress Report Table): Collects consistent, quantifiable, and up-to-date information on award recipients’ progress towards the funding goals and the funded projects’ impact on each participating health center.
Health Center Program Progress Report: This form is used to monitor activities approved in expanded services grants.
HRSA Loan Guarantee Program Application: Application to support loans guarantees to eligible Section 330 Health Center Program award recipients for construction/expansion, alteration/renovation, and modernization of health center medical facilities.
Health Center Program: Supplemental Information: Collects information from applicants regarding how funding will be used to increase the number of individuals assisted, enrollees and FTEs. Applicants also describe the strategies to implement funding activities.
Operational Plan: Outlines reasonable, time-framed goals and action steps necessary to become operational and compliant with the Health Center Program requirements within 120 days of the Notice of Award.
Other Requirements for Sites: Collects information on the proposed site(s) regarding ownership, site control, and historic preservation issues.
Participating Health Center List: Collects names of unique health centers (Health Center Program award recipients and look-alikes) that are committed to participating in the HCCN project.
Patient Target and Calculations: This form is used to confirm Patient Targets or request an update.
Project Narrative Update: Requires approved Section 330 award recipients to provide an update on progress and changes that have impacted the community/target population and award recipient organization, from the beginning of the budget period until the date of the submission; the expected progress for the remainder of the budget period; and projected plans for the entire budget period.
Project Overview Form: This form collects the project work plan, including proposed activities, and information about scope of project.
Project Plan: This form collects details related to project activities and outputs associated with project funding.
Project Qualification Criteria: Requires applicants to specifically address eligibility criteria identified in the funding opportunity.
Project Work Plan: Collects information from PCAs, NTTAPs, and HCCNs about the T/TA activities they plan to conduct for a given period of time.
Proposal Cover Page: Collects information from applicants that address how all projects together will address the needs of the community as well as the long-term impact of all projects. The form also requires applicants to explain how they plan to maintain improved access/services that will result from the project(s) within their existing operational budget/grant support.
QIF Progress Report (previously Quality Improvement Award Progress Report): This form collects progress related to overall project implementation.
QIF Project Plan (previously Quality Improvement Award Project Plan): This form collects information related to project goals, population of focus, community engagement approach, and barriers the proposed project will address. It also collects information on corresponding innovations.
Summary Page: Collects prepopulated key application data and components to enable SAC and NAP applicants to easily review and verify.
The following section below describes the revisions from the last clearance package:
The addition of new structured and non-structured forms:
The following forms are new forms for this clearance package.
Appliation Qualification Criteria Form: This form is used to validate SBHC application eligibility.
Financial Performance Indicators (Loan Guarantee Program): This form gathers key operational and financial data from health centers applying for the Health Center Loan Guarantee Program to permit HRSA to assess risk in making available a loan guarantee.
Funding Request Summary Form: Collects program specific information about the use of SBHC federal funding.
FY2022 Accelerating Cancer Screening Progress Report: This form collect status update on the activities supported with this funding.
NHHCIA NCC Clinical Performance Measures: Collects information on Native Hawaiian Health Systems’ progress on meeting targets for a set of clinical performance measures.
NHHCIA NCC Financial Performance Measures: Collects information on Native Hawaiian Health Systems’ progress on meeting targets for a set of financial performance measures.
NHHCIA NCC Income Analysis Form: Collects information on Native Hawaiian Health Care Systems’ expected income for the upcoming budget period.
NHHCIA NCC Project Work Plan Progress Report: Collects information on accomplishments for the prior budget period.
NHHCIA NCC Project Work Plan Update: Collects information on any planned changes to the work plan for the upcoming budget period.
Patient Impact Form: This form is used to collect SBHC baseline and estimated patient information, as well as SBHC progress on the number of patients served.
Project Cover Page: This form is used to collect information about alteration/renovation or construction projects.
Progress Report Non-Capital Investments: This form is used to collect status updates on all activities supported with non-Capital Investment funding.
School-Based Health Center (SBHC) Location Form: This form is used to provide information for proposed school-based health center location.
Quality Improvement (QIF) Evaluative Measures Report: This form is used to report information related to overall project implementation.
QIF Project Plan Form: This form collects information related to project goals, population of focus, community engagement approach, and barriers the proposed project will address. It also collects information on corresponding innovations.
QIF Progress Report: This form collects progress related to overall project implementation.
This section identifies the specific changes to previously cleared Health Center Program forms.
Checklist for Adding a New Service: Text changes to update instructions and hyperlinks.
Checklist for Adding a New Service Delivery Site: Text changes to update instructions and hyperlinks.
Checklist for Adding a New Target Population: Text changes to update instructions and hyperlinks.
Checklist for Deleting Existing Service: Text changes to update instructions and hyperlinks.
Checklist for Deleting Existing Service Delivery Site: Text changes to update instructions and hyperlinks.
Equipment List: No changes.
Expanded Services Patient Impact: Updated to reflect new name and to include new sections (Existing Patient Impact, New Patient Impact, and New Patient by Population Type).
Federal Object Class Categories: No changes.
Financial Performance Measures: Updated to reflect most recent list of Financial Performance Measures, Focus Area, Performance Measures, Numerator Description, and Denominator Description.
Form 1A: Text changes to update instructions for sections, project period dates, and section titles.
Form 1B: Text changes to update instructions and remove duplicative budget information.
Form 1C: Revised the list of required documents.
Form 2: Updated staff titles to align with UDS Manual.
Form 3: No changes.
Form 3A: Revised to remove instructions.
Form 4: Revised to update Note section and section titles.
Form 5A: No changes.
Form 5B: No changes.
Form 5C: No changes.
Form 6A: Text changes to update section instructions and category names.
Form 6B: Changes to section instructions.
Form 8: Changed to clarify questions and updated instructions.
Form 12: Updated to add additional staff and update burden estimate.
Funding Sources: No changes.
FY2020 Ending HIV Epidemic Primary Care HIV PCHP Progress Reporting: No changes.
HCCN Progress Report Table: Updated to include sections for “Enhanced the Patient and Provider Experience” and “Advance Interoperability.”
Health Center Progress Report: No changes.
HRSA Loan Guarantee Program Application: No changes.
Operational Plan: Updated to include additional instructions and revise focus areas.
Other Requirements for Sites: No changes.
Project Narrative Update Revised to update title (formerly Program Narrative Update) and to reflect updated/streamlined instructions.
Project Overview Form: Changes to the instructions and focus areas in order to let applicants describe their proposed activities.
Project Work Plan: Updated to combine the details for training and technical assistance activities to be conducted by PCAs, NTTAPs, and HCCNs.
Summary Page (Service Area Competition (SAC): Updated to separate the SAC and NAP summary pages into two documents.
3. Use of Improved Information Technology
The data collection forms are completed by applicants or award recipients using a web-based data collection system that is completely integrated with the HRSA EHBs. The HRSA EHBs provides authentication and authorization services to all applicants.
Application data can be submitted using standard web browsers through a Section 508 compliant user interface. The system presents users with electronic forms that clearly communicate what is required and provide assistance in completing their applications. Usability features such as those that pre-populate data from prior year applications based on business rules prevent redundant data entry. Users are able to work on the forms in part, save them online, and return to complete them later. Business rules are also in place in the system to ensure the data submitted meets the legislative and programmatic requirements. The users are provided with a summary of items that are complete, as well as incomplete, along with links to jump to the appropriate sections to complete the identified incomplete parts.
4. Efforts to Avoid Duplication
The applicant information requested in these forms is unique to these programs and is not captured elsewhere.
5. Involvement of Small Entities
This activity does not have a substantial impact on small entities or small businesses.
6. Consequences if Information Collected Less Frequently
If the information is not collected annually HRSA would be unable to make grant awards. The information is also required in order to monitor the progress of Health Center Program awardees to ensure that they are in compliance with section 330 of the PHS Act and Health Center Program policies, as well as to provide information required in reports to Congress.
7. Consistency with the Guidelines in 5 CFR 1320.5(d)(2)
The data are collected in a manner consistent with guidelines contained in 5 CFR 1320.5(d)(2).
8. Consultation Outside the Agency
The notice required by 5 CFR 1320.8(d) was published in the Federal Register on October 17, 2022 (Vol. 87, No. 199, page 62861). No comments were received.
The guidance and applications were provided to the National Association of Community Health Centers (NACHC) for review of the materials regarding clarity and the estimate of annualized burden. The NACHC members consulted were:
Ted Henson, Director, Health Center Performance & Innovation
Gervean Williams, Director, Health Center Financial Trainings
Jennifer Notly, Director, Innovative Primary Care
Emily Heard, Health Center Governance Training
Cindy Thomas, Director, Leadership Training and Cooperative Agreement Management
National Association of Community Health Centers
301-347-0400
The feedback from the external stakeholders indicates that the forms are clear and the allocation of time for most forms is reasonable. Based on comments received, burden estimates were increased for several forms.
9. Remuneration of Respondents
Respondents will not receive any payments or gifts.
10. Assurance of Confidentiality
No assurance of confidentiality is made to the applicants. These applications specify the reporting of aggregate data on users and the services they receive, in addition to descriptive information about each award recipient and its operations and financial systems. Award recipient-level data are covered under the Freedom of Information Act.
11. Questions of a Sensitive Nature
There are no questions of a sensitive nature.
12. Estimates of Annualized Hour Burden
Estimates of annualized reporting burden are as follows:
Form Name |
Number of Respondents |
Number of Responses per Respondent |
Total Responses |
Average Burden per Response (in hours) |
Total Burden Hours |
Applicant Qualification Criteria Form |
500 |
1 |
500 |
1 |
500 |
Capital Semi Annual Progress Report |
1,317 |
2 |
2,634 |
1 |
2,634 |
Checklist for Adding a New Service |
450 |
1 |
450 |
2 |
900 |
Checklist for Adding a New Service Delivery Site |
1,480 |
1 |
1,480 |
2 |
2,960 |
Checklist for Adding a New Target Population |
100 |
1 |
100 |
2 |
200 |
Checklist for Deleting Existing Service |
500 |
1 |
500 |
2 |
1,000 |
Checklist for Deleting Existing Service Delivery Site |
750 |
1 |
750 |
2 |
1,500 |
Equipment List |
1,375 |
1 |
1,375 |
0.5 |
688 |
Expanded Services Patient Impact |
996 |
1 |
996 |
1 |
996 |
Federal Object Class Categories Form |
735 |
1 |
735 |
0.25 |
184 |
Financial Performance Indicators |
20 |
1 |
20 |
1 |
20 |
Form 12: Organization Contacts |
1,058 |
1 |
1,058 |
1 |
1,058 |
Form 1A: General Information Worksheet |
1,058 |
1 |
1,058 |
1 |
1,058 |
Form 1B: Funding Request Summary |
1,000 |
1 |
1,000 |
0.75 |
750 |
Form 1C: Documents on File |
1,058 |
1 |
1,058 |
0.5 |
529 |
Form 2: Staffing Profile |
1,058 |
1 |
1,058 |
1 |
1,058 |
Form 3: Income Analysis |
1,058 |
1 |
1,058 |
1 |
1,058 |
Form 3A: Look-Alike Budget Information |
50 |
1 |
50 |
1 |
50 |
Form 4: Community Characteristics |
1,058 |
1 |
1,058 |
1 |
1,058 |
Form 5A: Services Provided |
1,058 |
1 |
1,058 |
1 |
1,058 |
Form 5B: Service Sites |
1,058 |
1 |
1,058 |
1 |
1,058 |
Form 5C: Other Activities/Locations |
1,058 |
1 |
1,058 |
1 |
1,058 |
Form 6A: Current Board Member Characteristics |
1,058 |
1 |
1,058 |
1 |
1,058 |
Form 6B: Request for Waiver of Board Member Requirements |
1,058 |
1 |
1,058 |
1 |
1,058 |
Form 8: Health Center Agreements |
1,058 |
1 |
1,058 |
1 |
1,058 |
Funding Request Summary Form (SBHC) |
500 |
1 |
500 |
0.5 |
250 |
Funding Sources |
735 |
1 |
735 |
0.5 |
368 |
FY2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting |
182 |
1 |
182 |
1 |
182 |
FY2022 Accelerating Cancer Screening Progress Report |
10 |
1 |
10 |
1.5 |
15 |
HCCN Progress Report |
90 |
1 |
90 |
1 |
90 |
Health Center Program Progress Report |
735 |
1 |
735 |
1 |
735 |
HRSA Loan Guarantee Program Application |
20 |
1 |
20 |
1 |
20 |
NHHCIA NCC Clinical Performance Measures |
6 |
1 |
6 |
1.5 |
9 |
NHHCIA NCC Financial Performance Measures |
6 |
1 |
6 |
0.5 |
3 |
NHHCIA NCC Income Analysis Form |
6 |
1 |
6 |
0.15 |
1 |
NHHCIA NCC Project Work Plan Progress Report |
6 |
1 |
6 |
0.15 |
1 |
NHHCIA NCC Project Work Plan Update |
6 |
1 |
6 |
0.15 |
1 |
Operational Plan |
500 |
1 |
500 |
3 |
1,500 |
Other Requirements for Sites |
600 |
1 |
600 |
0.5 |
300 |
Participating Health Centers List |
90 |
1 |
90 |
1 |
90 |
Patient Impact Form |
500 |
1 |
500 |
1 |
500 |
Patient Target and Calculations |
1,058 |
1 |
1,058 |
1 |
1,058 |
Progress Report - Non-Capital Investments |
1,400 |
4 |
5,600 |
1.5 |
8,400 |
Project Cover Page |
735 |
1 |
735 |
1 |
735 |
Project Narrative Update |
883 |
1 |
883 |
4 |
3,532 |
Project Overview Form |
500 |
1 |
500 |
1 |
500 |
Project Plan |
182 |
3 |
546 |
1.5 |
819 |
Project Qualification Criteria |
735 |
1 |
735 |
1 |
735 |
Project Work Plan |
135 |
1 |
135 |
4 |
540 |
Proposal Cover Page |
735 |
1 |
735 |
1 |
735 |
QIF Evaluative Measures Report |
12 |
1 |
12 |
1.5 |
18 |
QIF Progress Report |
12 |
1 |
12 |
1.5 |
18 |
QIF Project Plan Form |
100 |
1 |
100 |
1 |
100 |
Summary Page (NAP) |
500 |
1 |
500 |
1 |
500 |
Summary Page (SAC) |
450 |
1 |
450 |
0.5 |
225 |
|
32,798 |
|
39,279 |
|
46,529 |
The burden estimates for the applications and forms were based on previous experience with these forms and input from award recipients using the HRSA EHBs system and application forms.
Type of Respondent |
Total Burden Hours |
Hourly Wage Rate1 |
Total Respondent Costs |
Medical and Health Services Managers |
46,029 |
$95.90 |
$4,414,181 |
Total |
46,029 |
$95.90 |
$4,414,181 |
13. Estimates of other Total Annual Cost Burden to Respondents or Record Keepers/Capital Costs
The costs to respondents is comprised of their time, recordkeeping, reporting, data management, and auditing, as well as employer overhead and fringe benefits.
14. Estimates of Annualized Cost to the Government
The estimated annual cost to the government is approximately $154,046 (1 GS-11, 2 GS-13, 1 GS-14 FTEs – 40% time of work) for reviewing the forms, and for processing and providing notification to applicants.
15. Change in Burden
For this clearance request, each form is being submitted separately to accurately reflect the number of respondents per form. The OMB Inventory currently contains 59,242 burden hours for this activity. This request is for 46,029 total burden hours, for a decrease of 13,213 hours. The decrease in hours is due to the number of applicants that will be asked to leverage these forms. Additionally, the data needed for new funding opportunities could be captured in forms previously approved.
16. Plans for Analysis and Timetable of Key Activities
There will be no statistical analysis done on the information received nor will there be any publication of the information reported on the applications.
17. Exemption for Display of Expiration Date
The expiration date will be displayed.
18. Certifications
This project fully complies with CFR 1320.9. The certifications are included in this package.
1 Wages for Medical and Health Services Managers are based on Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Medical and Health Services Managers, on the Internet at http://www.bls.gov/ooh/management/medical-and-health-services-managers.htm (visited November 4, 2019), as well as employer overhead and fringe benefits.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | GENERIC - Supporting Statement Template |
| Author | Jodi.Duckhorn |
| File Modified | 0000-00-00 |
| File Created | 2024-11-27 |