Supporting Statement A

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SUPPORTING STATEMENT A
The Health Center Program Forms
OMB Control No. 0915-0285

Terms of Clearance:  None

A.	Justification

1.	Circumstances Making the Collection of Information Necessary

The Health Resources and Services Administration (HRSA) requests OMB approval of updated forms used by several HRSA Bureau of Primary Health Care (BPHC) programs providing grant funding and other federal benefits to serve medically underserved and vulnerable populations. The forms are currently approved under OMB number 0915-0285, Health Center Program Forms with an expiration of June 30, 2029. The revisions largely update the forms to align with policy updates to the change in scope process; facilitate monitoring of the Loan Guarantee Program; and collect final information for Quality Improvement Fund (QIF) awards, as directed in the notice of funding opportunity. Form 5C was removed from the package during revisions completed earlier in 2026 and was inadvertently retained in the published 60-day Federal Register Notice burden table. The burden effects of this correction are described in Sections 12 and 15.

The Health Center Program, administered by HRSA, is authorized under section 330 of the Public Health Service (PHS) Act (42 U.S.C. § 254b). 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. More than 1,400 health centers operate nearly 17,000 service delivery sites that provide primary health care to more than 32 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 merit 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 merit review committee panels to support application evaluation; funding recommendation and approval; designation; and monitoring. Health centers use a combination of the forms: 
 
    • Budget Period Progress Report (BPR), which provides HRSA an update on Health Center Program award recipients’ progress. 
    • Capital Development funding opportunities, which provide funding for construction, renovation, repair and/or improvement of health center service delivery sites. 
    • Change in Scope (CIS) requests, which health centers submit to HRSA to request changes in scope of project as it relates to services offered, sites, and other scope activities. 
    • Health Center Controlled Networks (HCCNs), which are groups of health centers working together to use health information technology (HIT) to improve operational and clinical practices. 
    • Loan Guarantee Program (LGP), which supports guarantees of up to 80% of the principal and interest on loans made by private lenders to eligible Health Center Program award recipients for the construction/expansion, alteration/renovation, and modernization of health center medical facilities.
    • Look-Alike (LAL) applications, which 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 Technical Assistance Partners (NTAPs), which provide technical assistance (TA) to potential and existing section 330-funded health centers with the goal of assisting them to address requirements of the Health Center Program, HHS and HRSA priorities, improve performance, and support program development and analysis activities.
    • Native Hawaiian Health Care Improvement Act (NHHCIA), which is a congressional special initiative to improve the provision of comprehensive disease prevention, health promotion, and primary care services to Native Hawaiians.
    • New Access Points (NAP), which 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), which are cooperative agreements between HRSA and state and regional organizations that provide TA to potential and existing health centers with the goal of assisting them to address requirements of the Health Center Program, HHS and HRSA priorities, improve performance, and support program development and analysis activities.
    • Quality Improvement Fund (QIF), which is a supplemental funding opportunity to support health centers to improve health outcomes by partnering with patients and the community to implement evidence-based models for increasing access to high-quality primary care services.
    • Service Area Competition (SAC), which 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 to population(s) in a service area.

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 and activities mentioned above. 

The following forms are used to collect the specified required information:  

    • Checklist for Form 5A Scope Adjustments:  Collect information about changes to scope related to services on Form 5A.
    • Checklist for Form 5B Scope Adjustments:  Collect information about changes to scope related to services on Form 5B.
    • Form 5A:  Services Provided:  Identifies the mode of service provision for all clinical and non-clinical services. 
    • Form 5B:  Sites (previously 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). 
    • 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 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 a Service Site from Scope  :  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
    • Capital Semi-Annual Progress Report:  This form is used to monitor semi-annual activities to document progress for Capital funding.
    • 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.
    • Federal Object Class Categories:  Collects budget information that is not included on the SF-424A for future years.
    • Loan Guarantee Program Financial Performance Indicators (previously: Financial Performance Indicators):  Collects information on specific financial performance measures for the Loan Guarantee program. 
    • 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 6A:  Current Board Member Characteristics:  Collects information on board members, including areas of expertise and years of service on the board.
    • Form 6B:  Request for Waiver of Board Member Requirements:  Used to request a waiver of governing board requirements. Only organizations seeking to serve only Homeless Populations, Migrant and Seasonal Agricultural Workers, or Residents of Public Housing 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 two contact people of the organization. 
    • Funding Sources:  Identifies other sources of funding that will be necessary to fund the overall project proposal.
    • FY2022 Accelerating Cancer Screening Progress Report:  This form collects a status update on the activities supported with this funding.
    • Grant Number Form:  Collects the grant number of current awardees. 
    • HCCN Progress Report:  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 collects information about activities, barriers faced, and lessons learned during the reporting period. It is used to monitor activities approved in expanded services grants.
    • HRSA Loan Guarantee Program Application:  This form is an application submitted by eligible Section 330 Health Center Program award recipients for HRSA loan guarantees to support construction/expansion, alteration/renovation, and modernization of health center medical facilities.
    • Impact Form (previously: Expanded Services Patient Impact):  This form is used to collect baseline and estimated patient information, as well as progress on the number of patients served.
    • 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 Sample Project Work Plan:  Collects information on accomplishments for the prior budget period.
    • NH-NCC Project Work Plan Update:  Collects information on any planned changes to 
    • the work plan for the upcoming budget period.
    • Operational Plan:  The form collects information about whether a health center is compliant with Health Center Program requirements and operational and, if not, how the Health Center will become compliant and operational within 120 days.
    • 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.
    • Project Cover Page:  This form is used to collect information about alteration/renovation or construction projects.
    • 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 Qualification Criteria:  Collects information for capital projects.
    • Project Work Plan:  Collects information from PCAs, NTAPs, and HCCNs about the T/TA activities they plan to conduct for a given period of time.
    • Proposal Cover Page:  Collects information from applicants about 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 Evaluative Measures Report:  This form is used to report information related to overall project implementation.
    • QIF Progress Report:  This form collects progress related to overall project implementation for QIF awards.
    • QIF TJI Evaluative Measures Report:  This form is used to report information related to overall project implementation for TJI awards.
    • QIF TJI Progress Report:  This form collects progress related to overall project implementation for TJI awards.
    • QIF 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 (New Access Point):  Collects prepopulated key application data and components to enable NAP applicants to easily review and verify.
    • Summary Page (Service Area Competition):  Collects prepopulated key application data and components to enable SAC applicants to easily review and verify.
    • LAL Cover Page:  Collects contact information and population types for look-alike initial designation and renewals. 
    • Checklist for Adding a Transitional Care in Carceral Setting Site to Scope:  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 transitional care in carceral setting to scope.

The following sections below describe the revisions from the last clearance package: 

    A. The following forms are new forms for this information collection request:

    • Checklist for Replacing a Service Site in Scope:  Checklist for updating a health center’s scope to replace a service site.
    • Quality Improvement Fund (QIF) Final Report:  Collects data on the award recipient’s QIF project progress as directed by the notice of funding opportunity
    • Loan Guarantee Progress Report:  A quarterly post-guarantee monitoring report covering loan balances, payment performance, and supporting financial documents.

    B. This section identifies the specific changes to previously cleared Health Center Program forms.
    • Form 5A: Services Provided: Updates labels and categories of services. 
    • Form 5B: Sites: Modifies fields collecting site information. 
    • Checklist for Form 5A Scope Adjustments: Revises checklist statements and questions. 
    • Checklist for Form 5B Scope Adjustments: Revises checklist statements and questions. 
    • Checklist for Deleting a Service Site from Scope (previously “Checklist for Deleting Existing Service Delivery Site”): Revises checklist statements and questions. 
    • Checklist for Adding a Service Site to Scope (previously “Checklist for Adding a New Service Delivery Site”): Revises checklist statements and questions. 
    • Checklist for Adding a Service to Scope (previously “Checklist for Adding a New Service”): Revises checklist statements and questions. 
    • Checklist for Deleting a Service from Scope (previously “Checklist for Deleting Existing Service”): Revises checklist statements and questions.

3.	Use of Improved Information Technology and Burden Reduction

The data collection forms are completed by applicants or award recipients through the Electronic Handbook (EHB) or Grants.gov. Applicants or award recipients submit forms to HRSA through the EHB or Grants.gov in one of two ways: 
        ◦ Submitted as attachments to applications (through EHB). 
        ◦ Submitted using a web-based data collection system within EHB.
EHB is compliant with Section 508 requirements for the visually impaired and fillable forms submitted in Grants.gov are Section 508 compliant.
4.	Efforts to Identify Duplication and Use of Similar Information

The applicant information requested in these forms is unique to these programs and is not captured elsewhere.

5.	Impact on Small Businesses or Other Small Entities

This activity does not have a substantial impact on small entities or small businesses. The information being requested or required has been limited to the minimum required for the intended use of the data in order to comply with program requirements. 

6.	Consequences of Collecting the Information Less Frequently

If the information is not collected at the required intervals, HRSA would be unable to make grant awards and fulfill its oversight and reporting responsibilities. While the burden is annualized for purposes of this estimate, collection frequency varies by form. Some forms are collected at the time of application and are used by reviewers to determine applicant eligibility and rank applications for funding. Other forms are required monthly or semi-annually, as specified in the terms and conditions of award, to support program monitoring, ensure compliance with section 330 of the PHS Act and Health Center Program policies, and provide information required for reports to Congress. Additional forms, such as those related to changes in scope, are submitted only when an organization elects to make changes to its approved project; accordingly, the timing and volume of these submissions are estimated based on prior experience. Less frequent collection would impair HRSA’s ability to make award decisions, monitor awardee progress, and fulfill its oversight and reporting responsibilities as specified in statute.

7.	Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

The data are collected in a manner consistent with guidelines contained in 5 CFR 1320.5(d)(2).

8.	Comments in Response to the Federal Register Notice/Outside Consultation

Section 8A: 

A 60-day Federal Register Notice was published in the Federal Register on July 30, 2026, vol. 91, No. 145; pp.  48170-72. There were no public comments.

Section 8B: 

HRSA did not conduct a separate, stand-alone consultation with people outside the HRSA solely for purposes of this submission. Instead, during the past two years, HRSA engaged a broad internal working group to assess and improve the forms. In doing so, the working group consolidated feedback obtained through ongoing program operations from a broad range of external stakeholders, including people from whom the information is collected.  HRSA relied on this ongoing, iterative feedback process to refine the forms and instructions rather than conducting a separate consultation process for this cycle.

9.	 Explanation of any Payment/Gift to Respondents 

Respondents will not receive any payments or gifts.

10.	Assurance of Confidentiality Provided to Respondents

No assurance of confidentiality is made to the applicants, any confidential or sensitive information that is collected will be protected from disclosure to the extent permitted by law, including the Freedom of Information Act, 5 U.S.C. § 552. Information is collected at the organizational level, and any information about individuals is not retrieved by a personal identifier.

In addition, access to the information collected is limited, on a need-to-know basis, to HRSA personnel whose official duties require such access, including personnel responsible for processing, reviewing, administering, or supporting the application process. Such information is not broadly available to all HRSA employees.

11.	Justification for Sensitive Questions

There are no questions of a sensitive nature.
	
12.	Estimates of Annualized Hour and Cost Burden

12A.        Estimated Annualized Burden Hours 

The burden estimates for the applications and forms were based on previous experience with these forms (i.e. number of respondents) and input from award recipients using the HRSA EHBs system and application forms. Based on the underlying unrounded burden calculations, these updates will reduce the estimated annual burden by 1,621 hours compared with the currently approved collection. The reduction reflects modifications to existing forms and the correction of the burden table to exclude Form 5C: Other Activities/Locations. Form 5C was removed from the package during revisions completed earlier in 2026 and was inadvertently retained in the published 60-day Federal Register Notice burden table. Excluding Form 5C reduces the 60-day notice totals by 550 respondents, 550 responses, and 137.50 burden hours.    In the burden table below, new forms are indicated through bold text, and revised forms are indicated through italicized text.  All other forms are unchanged.
Estimates of annualized reporting burden are as follows:
 
Number of Respondents
Number of Responses per respondent
Total Responses
Average Burden per response (hours)
Total Burden Hours
Form 5A: Services Provided 
1400
1
1400
0.25
350
Form 5B: Sites
1400
1
1400
0.25
350
Checklist for Form 5A Scope Adjustments 
1000
1
1000
1
1000
Checklist for Form 5B Scope Adjustments 
2000
1
2000
1
2000
Checklist for Deleting a Service Site from Scope  Previously:  Checklist for Deleting Existing Service Delivery Site 
500
1
500
1
500
Checklist for Adding a Service Site to Scope Previously: Checklist for Adding a New Service Delivery Site
1250
1
1250
1.5
1875
Checklist for Adding a Service to Scope Previously Checklist for adding a new service 
450
1
450
1
450
Checklist for Deleting a Service from Scope previously: Checklist for deleting existing service 
500
1
500
1
500
Checklist for Replacing a Service Site in Scope 
250
1
250
0.75
187.5
Quality Improvement Fund Final Report
25
1
25
3
75
Loan Guarantee Progress Report
22
4
88
1
88
Capital Semi-Annual Progress Report
500
2
1,000
1.00
1,000.00
Equipment List
130
1
130
0.50
65.00
Federal Object Class Categories Form
500
1
500
0.25
125.00
Loan Guarantee Program Financial Performance Indicators
5
1
5
1.00
5.00
Form 1A: General Information Worksheet
1,370
1
1,370
0.75
1,027.50
Form 1B: Funding Request Summary
900
1
900
0.75
675.00
Form 1C: Documents on File
1,460
1
1,460
0.50
730.00
Form 2: Staffing Profile
1,370
1
1,370
1.00
1,370.00
Form 3: Income Analysis
1,370
1
1,370
1.00
1,370.00
Form 6A: Current Board Member Characteristics
1,370
1
1,370
1.00
1,370.00
Form 6B: Request for Waiver of Board Member Requirements
1,370
1
1,370
1.00
1,370.00
Form 8: Health Center Agreements
1,370
1
1,370
1.00
1,370.00
Form 12: Organization Contacts
970
1
970
0.50
485.00
Funding Sources
130
1
130
0.50
65.00
FY 2022 Accelerating Cancer Screening Progress Report
29
1
29
1.50
43.50
Grant Number Form
400
1
400
0.25
100.00
HCCN Progress Report
50
1
50
0.50
25.00
Health Center Program Progress Report
130
1
130
1.00
130.00
HRSA Loan Guarantee Program Application
5
1
5
1.00
5.00
Impact Form 
400
1
400
1.00
400.00
NHHCIA NCC Clinical Performance Measures
5
1
5
1.50
7.50
NHHCIA NCC Financial Performance Measures
5
1
5
0.50
2.50
NHHCIA NCC Income Analysis Form
5
1
5
0.15
0.75
NHHCIA Sample Project Work Plan
2
1
2
0.15
0.30
NH-NCC Project Work Plan Update
5
1
5
1.00
5.00
Operational Plan
350
1
350
2.00
700.00
Other Requirements for Sites
130
1
130
0.50
65.00
Participating Health Centers List
90
1
90
1.00
90.00
Project Cover Page
130
1
130
1.00
130.00
Project Narrative Update
1,325
1
1,325
4.00
5,300.00
Project Overview Form
500
1
500
1.00
500.00
Project Qualification Criteria
130
1
130
0.50
65.00
Project Work Plan
508
1
508
4.00
2,032.00
Proposal Cover Page
130
1
130
1.00
130.00
QIF Evaluative Measures Report
25
2
50
1.50
75.00
QIF Progress Report
25
12
300
1.50
450.00
QIF TJI Evaluative Measures Report
54
10
540
1.50
810.00
QIF TJI Progress Report
54
10
540
1.50
810.00
QIF Project Plan Form
100
1
100
1.00
100.00
Summary Page (New Access Point)
500
1
500
1.00
500.00
Summary Page (Service Area Competition)
360
1
360
0.50
180.00
LAL Cover page
110
1
110
0.50
55.00
Checklist for Adding a Transitional Care in a Carceral Setting Site to Scope
50
1
50
1.00
50.00
Totals 
27,219.00
 
29,057.00
 
31,164.55

* The burden hours as listed in OIRA Consolidated Information System (ROCIS) total 31,167 due to rounding (i.e., forms with burden hours above 0.5 round up, below 0.5 round down).

12B 
The costs to respondents are comprised of their time, recordkeeping, reporting, data management, and auditing, as well as employer overhead and fringe benefits. HRSA expects Medical and Health Services Managers to be the employees completing the forms for this collection. 

Type of
Respondent
Total Burden
Hours
Hourly Median
Wage Rate
Total Respondent Costs
Medical and Health Services Managers (11-9111)
31,164.55
$119.10
$3,711,697.91
Total
31,164.55
$119.10
$3,711,697.91
Source:  Wages for Medical and Health Services Managers are based on Bureau of Labor Statistics, U.S. Department of Labor, May 2025 Occupational Employment and Wage Statistics Profiles., Medical and Health Services Managers, on the Internet at https://data.bls.gov/oesprofile/ (visited August 25, 2026). Hourly median wage doubled to account for benefits.


13.       Estimates of other Total Annual Cost Burden to Respondents or Recordkeepers/Capital 
	Costs

Other than their time, there is no cost to respondents.

14.	Annualized Cost to Federal Government

The estimated annual cost to the government is approximately $293,938.55 (1 GS-12, 2 GS-13, 1 GS-14 FTEs – 40% time of work) for reviewing the forms, and for processing and providing notification to applicants. Wage has been multiplied by 1.5 to account for overhead costs. 

Employee GS Grade
Annual Wage * 1.5
Number of Employees
Total (Hourly Wage * # of Employees * 0.40)
GS-12, Step 1
$153,621.81
1
$61,448.72
GS-13, Step 1
$182,677.41
2
$146,141.93
GS-14, Step 1
$215,869.76
1
$86,347.90
Total
$293,938.55


15.	Explanation for Program Changes or Adjustments

The OMB Inventory currently contains 32,785.55 burden hours for this activity. This request is for 31,164.55 total burden hours, for a decrease of 1,621 hours. The unrounded burden calculation for the current approved collection is 32,785.55 hours. This request is for 31,164.55 unrounded annual burden hours, a decrease of 1,621 unrounded hours. The decrease reflects modifications to existing forms and the correction of the burden table to exclude Form 5C: Other Activities/Locations. The program confirmed that Form 5C was removed from the package during revisions completed earlier in 2026 and was inadvertently retained in the published 60-day Federal Register Notice burden table. Excluding Form 5C reduces the 60-day notice totals by 550 annual responses and 137.50 annual burden hours.

16.	Plans for Tabulation, Publication, and Project Time Schedule
HRSA currently publishes selected public data elements from Scope forms through its public data warehouse (see https://data.hrsa.gov/topics/health-centers). HRSA will continue to assess whether additional public Scope form data elements can be incorporated into the warehouse over time.
HRSA currently does not publish certain data. This includes application data from SAC forms, and other materials associated with competitive NOFOs. These materials are not proactively published as open data because they are submitted as part of a competitive process and may contain sensitive applicant information, competition-related information, or other content that is not appropriate for public release. To the extent requests for these materials are received, they would be handled in accordance with applicable FOIA processes and other disclosure requirements. These materials are also not suitable for open-data publication in aggregated form because they are applicant-level, competition-specific, and often narrative in nature, such that aggregation would not adequately preserve context or resolve the underlying sensitivity concerns.
In addition, HRSA does not publish full progress report submissions. While certain information from progress reports can be reported publicly in aggregate, the full reports may contain recipient-specific or award-specific information that is not appropriate for public release at the individual submission level. For that reason, HRSA limits public reporting for progress reports to aggregated information where appropriate.

17.	Reason(s) Display of OMB Expiration Date is Inappropriate

The OMB number and Expiration date will be displayed on every page of every form.


18.	Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification.