OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

The Health Center Program Application Forms

ICR 202603-0915-004 · OMB 0915-0285 · Received in OIRA

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 52 2026 Checklist for Form 5B Scope Adjustments Form and Instruction New Available
Form 51 2026 Checklist for Form 5A Scope Adjustments Form and Instruction New Available
Form 50 2026 Checklist for Adding Care in a Transitional Care in Carceral Setting Site to Scope Form and Instruction New Available
Form 49 2026 LAL Cover page Form and Instruction New Available
Form 48 2026 Summary Page (Service Area Competition) Form and Instruction New Available
Form 45 2026 QIF TJI Progress Report Form and Instruction New Available
Form 44 2026 QIF TJI Evaluative Measures Report Form and Instruction New Available
Form 32 2026 NH-NCC Project Work Plan Update Form and Instruction New Available
Form 31 2026 NHHCIA Sample Project Work Plan Form and Instruction New Available
Form 23 2026 Grant Number form Form and Instruction New Available
Form 15 Funding Request Summary Form Form and Instruction Removed Available
Form 13 Applicant Qualification Criteria Form Form and Instruction Removed Available
Form 1 2026 Capital Semi Annual Progress Report Form and Instruction Modified Available
Form 22 2026 FY 2022 Accelerating Cancer Screening Progress Report Form and Instruction Modified Available
Form 42 2026 QIF Evaluative Measures Report Form and Instruction Modified Available
Form 36 2026 Project Cover Page Form and Instruction Modified Available
Form 7a Progress Report- Non-Capital Investments Form and Instruction Removed Available
Form 7a Patient Impact Form Form and Instruction Removed Available
Form 30 2026 NHHCIA NCC Income Analysis Form Form and Instruction Modified Available
Form 29 2026 NHHCIA NCC Financial Performance Measures Form and Instruction Modified Available
Form 28 2026 NHHCIA NCC Clinical Performance Measures Form and Instruction Modified Available
Form 46 2026 QIF Project Plan Form Form and Instruction Modified Available
Form 43 2026 QIF Progress Report Form and Instruction Modified Available
Form 38 Patient Target and Calculation.docx Form and Instruction Removed Available
Form 35 2026 Participating Health Centers List Form and Instruction Modified Available
Form 18E Form 3A - edits.docx Form and Instruction Removed Available
Form 18 Form 3A - clean.docx Form and Instruction Removed Available
Form 9 2026 Form 1A: General Information Worksheet Form and Instruction Modified Available
Form 26 2026 HRSA Loan Guarantee Program Application Form and Instruction Modified Available
Form 24 2026 HCCN Progress Report Form and Instruction Modified Available
Form 25 2026 Health Center Program Progress Report Form and Instruction Modified Available
Form 37 2026 Project Narrative Update Form and Instruction Modified Available
Form 47 2026 Summary Page (New Access Point) Form and Instruction Modified Available
Form 7 2026 7. Federal Object Class Categories Form Form and Instruction Modified Available
Form 29 Progress Report PCHP Mark Up_add new report 10.30.20.docx Form and Instruction Removed Available
Form 29 FY2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting.docx Form and Instruction Removed Available
Form 40 2026 Project Work Plan Form and Instruction Modified Available
Form 33 2026 Operational Plan Form and Instruction Modified Available
Form 39 2026 Project Qualification Criteria Form and Instruction Modified Available
Form 21 2026 Funding Sources Form and Instruction Modified Available
Form 27 2026 Impact Form Form and Instruction Modified Available
Form 4E Checklist for Adding a New Target Population edits.docx Form and Instruction Removed Available
Form 4 Checklist for Adding a New Target Population - Clean.docx Form and Instruction Removed Available
Form 34 2026 Other Requirements for Sites Form and Instruction Modified Available
Form 6 2026 Equipment List Form and Instruction Modified Available
Form 38 2026 Project Overview Form Form and Instruction Modified Available
Form 41 2026 Proposal Cover Page Form and Instruction Modified Available
Form 5 2026 5. Checklist for Deleting Existing Service Delivery Site Form and Instruction Modified Available
Form 3 2026 Checklist for Adding a New Service Delivery Site.docx Form and Instruction Modified Available
Form 4 2026 4. Checklist for Deleting Existing Service.docx Form and Instruction Modified Available
Form 2 2026 Checklist for Adding a New Service Form and Instruction Modified Available
Form 8 2026 Loan Guarantee Program Financial Performance Indicators Form and Instruction Modified Available
Form 20 2026 Form 12: Organization Contacts Form and Instruction Modified Available
Form 42 Project Plan.docx Form and Instruction Removed Available
Form 19 2026 Form 8: Health Center Agreements Form and Instruction Modified Available
Form 18 2026 Form 6B: Request for Waiver of Board Member Requirements Form and Instruction Modified Available
Form 17 2026 Form 6A: Current Board Member Characteristics Form and Instruction Modified Available
Form 16 2026 Form 5c: Other Activities-Locations Form and Instruction Modified Available
Form 15 2026 Form 5B: Sites Form and Instruction Modified Available
Form 14 2026 Form 5A: Services Provided Form and Instruction Modified Available
Form 19E Form 4 - edits.docx Form and Instruction Removed Available
Form 19 Form 4 - Clean.docx Form and Instruction Removed Available
Form 13 2026 Form 3: Income Analysis Form and Instruction Modified Available
Form 12 2026 Form 2: Staffing Profile Form and Instruction Modified Available
Form 11 2026 Form 1 C: Documents on File Form and Instruction Modified Available
Form 10 2026 Form 1B: Funding Request Summary Form and Instruction Modified Available
Supporting Statement A - 0915-0285 - BPHC - HCP Forms - Revision - 04222026 (Final to OMB).docx Supporting Statement A Uploaded 2026-04-22 Available
Comment 1_Davies_Transformative Consulting_0915-0285_UDS_02.13.2026.pdf Public Comments Uploaded 2026-02-13 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
279988 Checklist for Form 5B Scope Adjustments Form and Instruction New2026 Checklist for Form 5B Scope Adjustments
279987 Checklist for Form 5A Scope Adjustments Form and Instruction New2026 Checklist for Form 5A Scope Adjustments
279986 Checklist for Adding Care in a Transitional Care in Carceral Setting Site to Scope Form and Instruction New2026 Checklist for Adding Care in a Transitional Care in Carceral Setting Site to Scope
279985 LAL Cover page Form and Instruction New2026 LAL Cover page
279984 Summary Page (Service Area Competition) Form and Instruction New2026 Summary Page (Service Area Competition)
279983 QIF TJI Progress Report Form and Instruction New2026 QIF TJI Progress Report
279982 QIF TJI Evaluative Measures Report Form and Instruction New2026 QIF TJI Evaluative Measures Report
279925 NH-NCC Project Work Plan Update Form and Instruction New2026 NH-NCC Project Work Plan Update
279922 NHHCIA Sample Project Work Plan Form and Instruction New2026 NHHCIA Sample Project Work Plan
279884 2026 Grant Number Form Form and Instruction New2026 Grant Number form
258364 Funding Request Summary Form (SBHC) Form and Instruction RemovedFunding Request Summary Form
258356 Applicant Qualification Criteria Form Form and Instruction RemovedApplicant Qualification Criteria Form
258281 Capital Semi Annual Progress Report Form and Instruction Modified2026 Capital Semi Annual Progress Report
258277 FY 2022 Accelerating Cancer Screening Progress Report Form and Instruction Modified2026 FY 2022 Accelerating Cancer Screening Progress Report
258276 QIF Evaluative Measures Report Form and Instruction Modified2026 QIF Evaluative Measures Report
258275 Project Cover Page Form and Instruction Modified2026 Project Cover Page
258274 Progress Report Non-Capital Investment Form and Instruction RemovedProgress Report- Non-Capital Investments
258272 Patient Impact Form Form and Instruction RemovedPatient Impact Form
258270 NHHCIA NCC Income Analysis Form Form and Instruction Modified2026 NHHCIA NCC Income Analysis Form
258269 NHHCIA NCC Financial Performance Measures Form and Instruction Modified2026 NHHCIA NCC Financial Performance Measures
258267 NHHCIA NCC Clinical Performance Measures Form and Instruction Modified2026 NHHCIA NCC Clinical Performance Measures
258266 QIF Project Plan Form Form and Instruction Modified2026 QIF Project Plan Form
258265 QIF Progress Report Form and Instruction Modified2026 QIF Progress Report
239182 Patient Target and Calculations Form and Instruction RemovedPatient Target and Calculation.docx
239181 Participating Health Center List Form and Instruction Modified2026 Participating Health Centers List
239173 Form 3A: FQHC Look-Alike Budget Information Form and Instruction RemovedForm 3A - edits.docx
239173 Form 3A: FQHC Look-Alike Budget Information Form and Instruction RemovedForm 3A - clean.docx
239164 Form 1A: General Information Worksheet Form and Instruction Modified2026 Form 1A: General Information Worksheet
223046 HRSA Loan Guarantee Program Application Form and Instruction Modified2026 HRSA Loan Guarantee Program Application
223045 Health Center Controlled Networks (HCCN) Progress Report Table Form and Instruction Modified2026 HCCN Progress Report
223043 Health Center Program Progress Report Form and Instruction Modified2026 Health Center Program Progress Report
223042 Project Narrative Update Form and Instruction Modified2026 Project Narrative Update
223041 Summary Page (New Access Point) Form and Instruction Modified2026 Summary Page (New Access Point)
223040 Federal Object Class Categories Form and Instruction Modified2026 7. Federal Object Class Categories Form
207854 FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Form and Instruction RemovedProgress Report PCHP Mark Up_add new report 10.30.20.docx
207854 FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Form and Instruction RemovedFY2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting.docx
207848 Project Work Plan Form and Instruction Modified2026 Project Work Plan
207847 Operational Plan Form and Instruction Modified2026 Operational Plan
207846 Project Qualification Criteria Form and Instruction Modified2026 Project Qualification Criteria
207845 Funding Sources Form and Instruction Modified2026 Funding Sources
207844 Impact Form Form and Instruction Modified2026 Impact Form
207843 Checklist for Adding a New Target Population Form and Instruction RemovedChecklist for Adding a New Target Population edits.docx
207843 Checklist for Adding a New Target Population Form and Instruction RemovedChecklist for Adding a New Target Population - Clean.docx
193532 Other Requirements for Sites Form and Instruction Modified2026 Other Requirements for Sites
193531 Equipment List Form and Instruction Modified2026 Equipment List
193528 Project Overview Form Form and Instruction Modified2026 Project Overview Form
193527 Proposal Cover Page Form and Instruction Modified2026 Proposal Cover Page
193526 Checklist for Deleting Existing Service Delivery Site Form and Instruction Modified2026 5. Checklist for Deleting Existing Service Delivery Site
193525 Checklist for Adding a new Service Delivery Site Form and Instruction Modified2026 Checklist for Adding a New Service Delivery Site.docx
193523 Checklist for Deleting Existing Service Form and Instruction Modified2026 4. Checklist for Deleting Existing Service.docx
193522 Checklist for Adding New Service Form and Instruction Modified2026 Checklist for Adding a New Service
193520 Loan Guarantee Financial Performance Indicators Form and Instruction Modified2026 Loan Guarantee Program Financial Performance Indicators
180786 Form 12: Organization Contacts Form and Instruction Modified2026 Form 12: Organization Contacts
180783 Project Plan Form and Instruction RemovedProject Plan.docx
180781 Form 8: Health Center Agreements Form and Instruction Modified2026 Form 8: Health Center Agreements
180780 Form 6B: Request for Waiver of Board Member Requirements Form and Instruction Modified2026 Form 6B: Request for Waiver of Board Member Requirements
180779 Form 6A: Current Board Member Characteristics Form and Instruction Modified2026 Form 6A: Current Board Member Characteristics
180778 Form 5C: Other Activities/Locations Form and Instruction Modified2026 Form 5c: Other Activities-Locations
180777 Form 5B: Sites Form and Instruction Modified2026 Form 5B: Sites
180776 Form 5A: Services Provided Form and Instruction Modified2026 Form 5A: Services Provided
180775 Form 4: Community Characteristics Form and Instruction RemovedForm 4 - edits.docx
180775 Form 4: Community Characteristics Form and Instruction RemovedForm 4 - Clean.docx
180774 Form 3: Income Analysis Form and Instruction Modified2026 Form 3: Income Analysis
180773 Form 2: Staffing Profile Form and Instruction Modified2026 Form 2: Staffing Profile
180772 Form 1C: Documents on File Form and Instruction Modified2026 Form 1 C: Documents on File
180771 Form 1B: BPHC Funding Request Summary Form and Instruction Modified2026 Form 1B: Funding Request Summary

ICR Details

Reginfo record details
table that charts list comparision
  Requested Previously Approved
36 Months From Approved 04/30/2026
30,350 39,279
32,789 47,058
0 0
Reginfo record details
52
table that charts list of burden
IC Title Form No. Form Name
2026 Grant Number Form 23
Applicant Qualification Criteria Form 13
Capital Semi Annual Progress Report 1
Checklist for Adding Care in a Transitional Care in Carceral Setting Site to Scope 50
Checklist for Adding New Service 2
Checklist for Adding a New Target Population 4E, 4 ,  
Checklist for Adding a new Service Delivery Site 3
Checklist for Deleting Existing Service 4
Checklist for Deleting Existing Service Delivery Site 5
Checklist for Form 5A Scope Adjustments 51
Checklist for Form 5B Scope Adjustments 52
Equipment List 6
FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting 29, 29 ,  
FY 2022 Accelerating Cancer Screening Progress Report 22
Federal Object Class Categories 7
Form 12: Organization Contacts 20
Form 1A: General Information Worksheet 9
Form 1B: BPHC Funding Request Summary 10
Form 1C: Documents on File 11
Form 2: Staffing Profile 12
Form 3: Income Analysis 13
Form 3A: FQHC Look-Alike Budget Information 18, 18E ,  
Form 4: Community Characteristics 19, 19E ,  
Form 5A: Services Provided 14
Form 5B: Sites 15
Form 5C: Other Activities/Locations 16
Form 6A: Current Board Member Characteristics 17
Form 6B: Request for Waiver of Board Member Requirements 18
Form 8: Health Center Agreements 19
Funding Request Summary Form (SBHC) 15
Funding Sources 21
HRSA Loan Guarantee Program Application 26
Health Center Controlled Networks (HCCN) Progress Report Table 24
Health Center Program Progress Report 25
Impact Form 27
LAL Cover page 49
Loan Guarantee Financial Performance Indicators 8
NH-NCC Project Work Plan Update 32
NHHCIA NCC Clinical Performance Measures 28
NHHCIA NCC Financial Performance Measures 29
NHHCIA NCC Income Analysis Form 30
NHHCIA Sample Project Work Plan 31
Operational Plan 33
Other Requirements for Sites 34
Participating Health Center List 35
Patient Impact Form 7a
Patient Target and Calculations 38
Progress Report Non-Capital Investment 7a
Project Cover Page 36
Project Narrative Update 37
Project Overview Form 38
Project Plan 42
Project Qualification Criteria 39
Project Work Plan 40
Proposal Cover Page 41
QIF Evaluative Measures Report 42
QIF Progress Report 43
QIF Project Plan Form 46
QIF TJI Evaluative Measures Report 44
QIF TJI Progress Report 45
Summary Page (New Access Point) 47
Summary Page (Service Area Competition) 48
table that charts list 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 30,350 39,279 0 -8,929 0 0
Annual Time Burden (Hours) 32,789 47,058 0 -14,269 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Reginfo record details
  No