The Health Center Program Application Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 55 Quality Improvement Fund (QIF) Final Report	Form and Instruction	New	Available
Form 54 Loan Guarantee Progress Report	Form and Instruction	New	Available
Form 53 Checklist for Replacing a Service Site in Scope	Form and Instruction	New	Available
Form 52 Checklist for Form 5B Scope Adjustments	Form and Instruction	Modified	Available
Form 51 Checklist for Form 5A Scope Adjustments	Form and Instruction	Modified	Available
Form 50 Checklist for Adding a Transitional Care in a Carceral Setting Site to Scop	Form and Instruction	Modified	Available
Form 49 LAL Cover page	Form and Instruction	Modified	Available
Form 48 Summary Page (Service Area Competition)	Form and Instruction	Modified	Available
Form 45 QIF TJI Progress Report	Form and Instruction	Modified	Available
Form 44 QIF TJI Evaluative Measures Report	Form and Instruction	Modified	Available
Form 32 NH-NCC Project Work Plan Update	Form and Instruction	Modified	Available
Form 31 NHHCIA Sample Project Work Plan	Form and Instruction	Modified	Available
Form 23 Grant Number form	Form and Instruction	Modified	Available
Form 1 Capital Semi Annual Progress Report	Form and Instruction	Modified	Available
Form 22 FY 2022 Accelerating Cancer Screening Progress Report	Form and Instruction	Modified	Available
Form 42 QIF Evaluative Measures Report	Form and Instruction	Modified	Available
Form 36 Project Cover Page	Form and Instruction	Modified	Available
Form 30 NHHCIA NCC Income Analysis Form	Form and Instruction	Modified	Available
Form 29 NHHCIA NCC Financial Performance Measures	Form and Instruction	Modified	Available
Form 28 NHHCIA NCC Clinical Performance Measures	Form and Instruction	Modified	Available
Form 46 QIF Project Plan Form	Form and Instruction	Modified	Available
Form 43 QIF Progress Report	Form and Instruction	Modified	Available
Form 35 Participating Health Centers List	Form and Instruction	Modified	Available
Form 9 Form 1A: General Information Worksheet	Form and Instruction	Modified	Available
Form 26 HRSA Loan Guarantee Program Application	Form and Instruction	Modified	Available
Form 24 HCCN Progress Report	Form and Instruction	Modified	Available
Form 25 Health Center Program Progress Report	Form and Instruction	Modified	Available
Form 37 Project Narrative Update	Form and Instruction	Modified	Available
Form 47 Summary Page (New Access Point)	Form and Instruction	Modified	Available
Form 7 Federal Object Class Categories Form	Form and Instruction	Modified	Available
Form 40 Project Work Plan	Form and Instruction	Modified	Available
Form 33 Operational Plan	Form and Instruction	Modified	Available
Form 39 Project Qualification Criteria	Form and Instruction	Modified	Available
Form 21 Funding Sources	Form and Instruction	Modified	Available
Form 27 Impact Form	Form and Instruction	Modified	Available
Form 34 Other Requirements for Sites	Form and Instruction	Modified	Available
Form 6 Equipment List	Form and Instruction	Modified	Available
Form 38 Project Overview Form	Form and Instruction	Modified	Available
Form 41 Proposal Cover Page	Form and Instruction	Modified	Available
Form 5 Checklist for Deleting a Service Site from Scope	Form and Instruction	Modified	Available
Form 3 Checklist for Adding a Service Site to Scope	Form and Instruction	Modified	Available
Form 4 Checklist for Deleting a Service from Scope	Form and Instruction	Modified	Available
Form 2 Checklist for Adding a Service to Scope	Form and Instruction	Modified	Available
Form 8 Loan Guarantee Program Financial Performance Indicators	Form and Instruction	Modified	Available
Form 20 Form 12: Organization Contacts	Form and Instruction	Modified	Available
Form 19 Form 8: Health Center Agreements	Form and Instruction	Modified	Available
Form 18 Form 6A: Current Board Member Characteristics	Form and Instruction	Modified	Available
Form 17 Form 6A: Current Board Member Characteristics	Form and Instruction	Modified	Available
Form 16 2026 Form 5c: Other Activities-Locations	Form and Instruction	Removed	Available
Form 15 Form 5B: Sites	Form and Instruction	Modified	Available
Form 14 Form 5A: Services Provided	Form and Instruction	Modified	Available
Form 13 Form 3: Income Analysis	Form and Instruction	Modified	Available
Form 12 Form 2: Staffing Profile	Form and Instruction	Modified	Available
Form 11 Form 1C: Documents on File	Form and Instruction	Modified	Available
Form 10 Form 1B: Funding Request Summary	Form and Instruction	Modified	Available
Supporting Statement A - 0915-0285 - BPHC - HCP Forms - Revision -10142026.docx	Supporting Statement A	Uploaded 2026-10-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
283198	Quality Improvement Fund (QIF) Final Report	Form and Instruction	New	Quality Improvement Fund (QIF) Final Report
283197	Loan Guarantee Progress Report:	Form and Instruction	New	Loan Guarantee Progress Report
283196	Checklist for Replacing a Service Site in Scope:	Form and Instruction	New	Checklist for Replacing a Service Site in Scope
279988	Checklist for Form 5B Scope Adjustments	Form and Instruction	Modified	Checklist for Form 5B Scope Adjustments
279987	Checklist for Form 5A Scope Adjustments	Form and Instruction	Modified	Checklist for Form 5A Scope Adjustments
279986	Checklist for Adding Care in a Transitional Care in Carceral Setting Site to Scope	Form and Instruction	Modified	Checklist for Adding a Transitional Care in a Carceral Setting Site to Scop
279985	LAL Cover page	Form and Instruction	Modified	LAL Cover page
279984	Summary Page (Service Area Competition)	Form and Instruction	Modified	Summary Page (Service Area Competition)
279983	QIF TJI Progress Report	Form and Instruction	Modified	QIF TJI Progress Report
279982	QIF TJI Evaluative Measures Report	Form and Instruction	Modified	QIF TJI Evaluative Measures Report
279925	NH-NCC Project Work Plan Update	Form and Instruction	Modified	NH-NCC Project Work Plan Update
279922	NHHCIA Sample Project Work Plan	Form and Instruction	Modified	NHHCIA Sample Project Work Plan
279884	2026 Grant Number Form	Form and Instruction	Modified	Grant Number form
258281	Capital Semi Annual Progress Report	Form and Instruction	Modified	Capital Semi Annual Progress Report
258277	FY 2022 Accelerating Cancer Screening Progress Report	Form and Instruction	Modified	FY 2022 Accelerating Cancer Screening Progress Report
258276	QIF Evaluative Measures Report	Form and Instruction	Modified	QIF Evaluative Measures Report
258275	Project Cover Page	Form and Instruction	Modified	Project Cover Page
258270	NHHCIA NCC Income Analysis Form	Form and Instruction	Modified	NHHCIA NCC Income Analysis Form
258269	NHHCIA NCC Financial Performance Measures	Form and Instruction	Modified	NHHCIA NCC Financial Performance Measures
258267	NHHCIA NCC Clinical Performance Measures	Form and Instruction	Modified	NHHCIA NCC Clinical Performance Measures
258266	QIF Project Plan Form	Form and Instruction	Modified	QIF Project Plan Form
258265	QIF Progress Report	Form and Instruction	Modified	QIF Progress Report
239181	Participating Health Center List	Form and Instruction	Modified	Participating Health Centers List
239164	Form 1A: General Information Worksheet	Form and Instruction	Modified	Form 1A: General Information Worksheet
223046	HRSA Loan Guarantee Program Application	Form and Instruction	Modified	HRSA Loan Guarantee Program Application
223045	Health Center Controlled Networks (HCCN) Progress Report	Form and Instruction	Modified	HCCN Progress Report
223043	Health Center Program Progress Report	Form and Instruction	Modified	Health Center Program Progress Report
223042	Project Narrative Update	Form and Instruction	Modified	Project Narrative Update
223041	Summary Page (New Access Point)	Form and Instruction	Modified	Summary Page (New Access Point)
223040	Federal Object Class Categories	Form and Instruction	Modified	Federal Object Class Categories Form
207848	Project Work Plan	Form and Instruction	Modified	Project Work Plan
207847	Operational Plan	Form and Instruction	Modified	Operational Plan
207846	Project Qualification Criteria	Form and Instruction	Modified	Project Qualification Criteria
207845	Funding Sources	Form and Instruction	Modified	Funding Sources
207844	Impact Form	Form and Instruction	Modified	Impact Form
193532	Other Requirements for Sites	Form and Instruction	Modified	Other Requirements for Sites
193531	Equipment List	Form and Instruction	Modified	Equipment List
193528	Project Overview Form	Form and Instruction	Modified	Project Overview Form
193527	Proposal Cover Page	Form and Instruction	Modified	Proposal Cover Page
193526	Checklist for Deleting a Service Site from Scope	Form and Instruction	Modified	Checklist for Deleting a Service Site from Scope
193525	Checklist for Adding a Service Site to Scope	Form and Instruction	Modified	Checklist for Adding a Service Site to Scope
193523	Checklist for Deleting a Service from Scope	Form and Instruction	Modified	Checklist for Deleting a Service from Scope
193522	Checklist for Adding a Service to Scope	Form and Instruction	Modified	Checklist for Adding a Service to Scope
193520	Loan Guarantee Financial Performance Indicators	Form and Instruction	Modified	Loan Guarantee Program Financial Performance Indicators
180786	Form 12: Organization Contacts	Form and Instruction	Modified	Form 12: Organization Contacts
180781	Form 8: Health Center Agreements	Form and Instruction	Modified	Form 8: Health Center Agreements
180780	Form 6B: Request for Waiver of Board Member Requirements	Form and Instruction	Modified	Form 6A: Current Board Member Characteristics
180779	Form 6A: Current Board Member Characteristics	Form and Instruction	Modified	Form 6A: Current Board Member Characteristics
180778	Form 5C: Other Activities/Locations	Form and Instruction	Removed	2026 Form 5c: Other Activities-Locations
180777	Form 5B: Sites	Form and Instruction	Modified	Form 5B: Sites
180776	Form 5A: Services Provided	Form and Instruction	Modified	Form 5A: Services Provided
180774	Form 3: Income Analysis	Form and Instruction	Modified	Form 3: Income Analysis
180773	Form 2: Staffing Profile	Form and Instruction	Modified	Form 2: Staffing Profile
180772	Form 1C: Documents on File	Form and Instruction	Modified	Form 1C: Documents on File
180771	Form 1B: BPHC Funding Request Summary	Form and Instruction	Modified	Form 1B: Funding Request Summary

ICR Details

OMB Control No: 0915-0285	ICR Reference No: 202610-0915-001
Status: Received in OIRA	Previous ICR Reference No: 202603-0915-004
Agency/Subagency: HHS/HSA	Agency Tracking No: 21063
Title: The Health Center Program Application Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/21/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2029
Responses	29,057	30,350
Time Burden (Hours)	31,167	32,789
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 Name of Law: Health Centers, Public Health Service Act (Section 330), as amended
  

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:
	91 FR 48170	07/30/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 66337	10/20/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 54

table that charts list of burden

IC Title	Form No.	Form Name
2026 Grant Number Form	23	Grant Number form
Capital Semi Annual Progress Report	1	Capital Semi Annual Progress Report
Checklist for Adding Care in a Transitional Care in Carceral Setting Site to Scope	50	Checklist for Adding a Transitional Care in a Carceral Setting Site to Scop
Checklist for Adding a Service Site to Scope	3	Checklist for Adding a Service Site to Scope
Checklist for Adding a Service to Scope	2	Checklist for Adding a Service to Scope
Checklist for Deleting a Service Site from Scope	5	Checklist for Deleting a Service Site from Scope
Checklist for Deleting a Service from Scope	4	Checklist for Deleting a Service from Scope
Checklist for Form 5A Scope Adjustments	51	Checklist for Form 5A Scope Adjustments
Checklist for Form 5B Scope Adjustments	52	Checklist for Form 5B Scope Adjustments
Checklist for Replacing a Service Site in Scope:	53	Checklist for Replacing a Service Site in Scope
Equipment List	6	Equipment List
FY 2022 Accelerating Cancer Screening Progress Report	22	FY 2022 Accelerating Cancer Screening Progress Report
Federal Object Class Categories	7	Federal Object Class Categories Form
Form 12: Organization Contacts	20	Form 12: Organization Contacts
Form 1A: General Information Worksheet	9	Form 1A: General Information Worksheet
Form 1B: BPHC Funding Request Summary	10	Form 1B: Funding Request Summary
Form 1C: Documents on File	11	Form 1C: Documents on File
Form 2: Staffing Profile	12	Form 2: Staffing Profile
Form 3: Income Analysis	13	Form 3: Income Analysis
Form 5A: Services Provided	14	Form 5A: Services Provided
Form 5B: Sites	15	Form 5B: Sites
Form 5C: Other Activities/Locations	16	2026 Form 5c: Other Activities-Locations
Form 6A: Current Board Member Characteristics	17	Form 6A: Current Board Member Characteristics
Form 6B: Request for Waiver of Board Member Requirements	18	Form 6A: Current Board Member Characteristics
Form 8: Health Center Agreements	19	Form 8: Health Center Agreements
Funding Sources	21	Funding Sources
HRSA Loan Guarantee Program Application	26	HRSA Loan Guarantee Program Application
Health Center Controlled Networks (HCCN) Progress Report	24	HCCN Progress Report
Health Center Program Progress Report	25	Health Center Program Progress Report
Impact Form	27	Impact Form
LAL Cover page	49	LAL Cover page
Loan Guarantee Financial Performance Indicators	8	Loan Guarantee Program Financial Performance Indicators
Loan Guarantee Progress Report:	54	Loan Guarantee Progress Report
NH-NCC Project Work Plan Update	32	NH-NCC Project Work Plan Update
NHHCIA NCC Clinical Performance Measures	28	NHHCIA NCC Clinical Performance Measures
NHHCIA NCC Financial Performance Measures	29	NHHCIA NCC Financial Performance Measures
NHHCIA NCC Income Analysis Form	30	NHHCIA NCC Income Analysis Form
NHHCIA Sample Project Work Plan	31	NHHCIA Sample Project Work Plan
Operational Plan	33	Operational Plan
Other Requirements for Sites	34	Other Requirements for Sites
Participating Health Center List	35	Participating Health Centers List
Project Cover Page	36	Project Cover Page
Project Narrative Update	37	Project Narrative Update
Project Overview Form	38	Project Overview Form
Project Qualification Criteria	39	Project Qualification Criteria
Project Work Plan	40	Project Work Plan
Proposal Cover Page	41	Proposal Cover Page
QIF Evaluative Measures Report	42	QIF Evaluative Measures Report
QIF Progress Report	43	QIF Progress Report
QIF Project Plan Form	46	QIF Project Plan Form
QIF TJI Evaluative Measures Report	44	QIF TJI Evaluative Measures Report
QIF TJI Progress Report	45	QIF TJI Progress Report
Quality Improvement Fund (QIF) Final Report	55	Quality Improvement Fund (QIF) Final Report
Summary Page (New Access Point)	47	Summary Page (New Access Point)
Summary Page (Service Area Competition)	48	Summary Page (Service Area Competition)

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ICR Summary of Burden

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	29,057	30,350	0	-743	-550	0
Annual Time Burden (Hours)	31,167	32,789	0	-1,484	-138	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: Yes

Burden Reduction Due to: Changing Forms

Short Statement: This revision updates eight currently approved forms and adds three new forms. The revisions streamline and clarify existing data collection requirements and are expected to reduce respondent burden. The three new forms add 350.5 annual burden hours; however, these hours are more than offset by burden reductions associated with the revised forms and the exclusion of Form 5C: Other Activities/Locations. Form 5C accounts for 550 annual responses and 137.5 annual burden hours and had been discontinued by the program during the earlier 2026 package revision but was inadvertently retained in the published 60-day Federal Register Notice burden table. Overall, the unrounded annual burden decreases from 32,785.55 hours to 31,164.55 hours, a net reduction of 1,621 hours.

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Annual Cost to Federal Government: $293,938

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: 10/21/2026

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