OMB control number

The Health Center Program Application Forms

OMB 0915-0285 · HHS/HSA.

OMB 0915-0285

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.

The latest form for The Health Center Program Application Forms expires 2029-06-30 and is listed under ICR 202603-0915-004.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form 52 2026 Checklist for Form 5B Scope Adjustments	Form and Instruction
Form 51 2026 Checklist for Form 5A Scope Adjustments	Form and Instruction
Form 50 2026 Checklist for Adding Care in a Transitional Care in Carceral Setting Site to Scope	Form and Instruction
Form 49 2026 LAL Cover page	Form and Instruction
Form 48 2026 Summary Page (Service Area Competition)	Form and Instruction
Form 45 2026 QIF TJI Progress Report	Form and Instruction
Form 44 2026 QIF TJI Evaluative Measures Report	Form and Instruction
Form 32 2026 NH-NCC Project Work Plan Update	Form and Instruction
Form 31 2026 NHHCIA Sample Project Work Plan	Form and Instruction
Form 23 2026 Grant Number form	Form and Instruction
Form 15 Funding Request Summary Form	Form and Instruction
Form 13 Applicant Qualification Criteria Form	Form and Instruction
Form 1 2026 Capital Semi Annual Progress Report	Form and Instruction
Form 22 2026 FY 2022 Accelerating Cancer Screening Progress Report	Form and Instruction
Form 42 2026 QIF Evaluative Measures Report	Form and Instruction
Form 36 2026 Project Cover Page	Form and Instruction
Form 7a Progress Report- Non-Capital Investments	Form and Instruction
Form 7a Patient Impact Form	Form and Instruction
Form 30 2026 NHHCIA NCC Income Analysis Form	Form and Instruction
Form 29 2026 NHHCIA NCC Financial Performance Measures	Form and Instruction
Form 28 2026 NHHCIA NCC Clinical Performance Measures	Form and Instruction
Form 46 2026 QIF Project Plan Form	Form and Instruction
Form 43 2026 QIF Progress Report	Form and Instruction
Form 38 Patient Target and Calculation.docx	Form and Instruction
Form 35 2026 Participating Health Centers List	Form and Instruction
Form 18E Form 3A - edits.docx	Form and Instruction
Form 18 Form 3A - clean.docx	Form and Instruction
Form 9 2026 Form 1A: General Information Worksheet	Form and Instruction
Form 26 2026 HRSA Loan Guarantee Program Application	Form and Instruction
Form 24 2026 HCCN Progress Report	Form and Instruction
Form 25 2026 Health Center Program Progress Report	Form and Instruction
Form 37 2026 Project Narrative Update	Form and Instruction
Form 47 2026 Summary Page (New Access Point)	Form and Instruction
Form 7 2026 7. Federal Object Class Categories Form	Form and Instruction
Form 29 Progress Report PCHP Mark Up_add new report 10.30.20.docx	Form and Instruction
Form 29 FY2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting.docx	Form and Instruction
Form 40 2026 Project Work Plan	Form and Instruction
Form 33 2026 Operational Plan	Form and Instruction
Form 39 2026 Project Qualification Criteria	Form and Instruction
Form 21 2026 Funding Sources	Form and Instruction
Form 27 2026 Impact Form	Form and Instruction
Form 4E Checklist for Adding a New Target Population edits.docx	Form and Instruction
Form 4 Checklist for Adding a New Target Population - Clean.docx	Form and Instruction
Form 34 2026 Other Requirements for Sites	Form and Instruction
Form 6 2026 Equipment List	Form and Instruction
Form 38 2026 Project Overview Form	Form and Instruction
Form 41 2026 Proposal Cover Page	Form and Instruction
Form 5 2026 5. Checklist for Deleting Existing Service Delivery Site	Form and Instruction
Form 3 2026 Checklist for Adding a New Service Delivery Site.docx	Form and Instruction
Form 4 2026 4. Checklist for Deleting Existing Service.docx	Form and Instruction
Form 2 2026 Checklist for Adding a New Service	Form and Instruction
Form 8 2026 Loan Guarantee Program Financial Performance Indicators	Form and Instruction
Form 20 2026 Form 12: Organization Contacts	Form and Instruction
Form 42 Project Plan.docx	Form and Instruction
Form 19 2026 Form 8: Health Center Agreements	Form and Instruction
Form 18 2026 Form 6B: Request for Waiver of Board Member Requirements	Form and Instruction
Form 17 2026 Form 6A: Current Board Member Characteristics	Form and Instruction
Form 16 2026 Form 5c: Other Activities-Locations	Form and Instruction
Form 15 2026 Form 5B: Sites	Form and Instruction
Form 14 2026 Form 5A: Services Provided	Form and Instruction
Form 19E Form 4 - edits.docx	Form and Instruction
Form 19 Form 4 - Clean.docx	Form and Instruction
Form 13 2026 Form 3: Income Analysis	Form and Instruction
Form 12 2026 Form 2: Staffing Profile	Form and Instruction
Form 11 2026 Form 1 C: Documents on File	Form and Instruction
Form 10 2026 Form 1B: Funding Request Summary	Form and Instruction
Supporting Statement A - 0915-0285 - BPHC - HCP Forms - Revision - 04222026 (Final to OMB).docx	Supporting Statement A
Comment 1_Davies_Transformative Consulting_0915-0285_UDS_02.13.2026.pdf	Public Comments
Checklist for Form 5B Scope Adjustments	Form and Instruction
Checklist for Form 5A Scope Adjustments	Form and Instruction
Checklist for Adding Care in a Transitional Care in Carceral Setting Site to Scope	Form and Instruction
LAL Cover page	Form and Instruction
Summary Page (Service Area Competition)	Form and Instruction
QIF TJI Progress Report	Form and Instruction
QIF TJI Evaluative Measures Report	Form and Instruction
NH-NCC Project Work Plan Update	Form and Instruction
NHHCIA Sample Project Work Plan	Form and Instruction
2026 Grant Number Form	Form and Instruction
Funding Request Summary Form (SBHC)	Form and Instruction
Applicant Qualification Criteria Form	Form and Instruction
Capital Semi Annual Progress Report	Form and Instruction
FY 2022 Accelerating Cancer Screening Progress Report	Form and Instruction
QIF Evaluative Measures Report	Form and Instruction
Project Cover Page	Form and Instruction
Progress Report Non-Capital Investment	Form and Instruction
Patient Impact Form	Form and Instruction
NHHCIA NCC Income Analysis Form	Form and Instruction
NHHCIA NCC Financial Performance Measures	Form and Instruction
NHHCIA NCC Clinical Performance Measures	Form and Instruction
QIF Project Plan Form	Form and Instruction
QIF Progress Report	Form and Instruction
Patient Target and Calculations	Form and Instruction
Participating Health Center List	Form and Instruction
Form 3A: FQHC Look-Alike Budget Information	Form and Instruction
Form 3A: FQHC Look-Alike Budget Information	Form and Instruction
Form 1A: General Information Worksheet	Form and Instruction
HRSA Loan Guarantee Program Application	Form and Instruction
Health Center Controlled Networks (HCCN) Progress Report Table	Form and Instruction
Health Center Program Progress Report	Form and Instruction
Project Narrative Update	Form and Instruction
Summary Page (New Access Point)	Form and Instruction
Federal Object Class Categories	Form and Instruction
FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting	Form and Instruction
FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting	Form and Instruction
Project Work Plan	Form and Instruction
Operational Plan	Form and Instruction
Project Qualification Criteria	Form and Instruction
Funding Sources	Form and Instruction
Impact Form	Form and Instruction
Checklist for Adding a New Target Population	Form and Instruction
Checklist for Adding a New Target Population	Form and Instruction
Other Requirements for Sites	Form and Instruction
Equipment List	Form and Instruction
Project Overview Form	Form and Instruction
Proposal Cover Page	Form and Instruction
Checklist for Deleting Existing Service Delivery Site	Form and Instruction
Checklist for Adding a new Service Delivery Site	Form and Instruction
Checklist for Deleting Existing Service	Form and Instruction
Checklist for Adding New Service	Form and Instruction
Loan Guarantee Financial Performance Indicators	Form and Instruction
Form 12: Organization Contacts	Form and Instruction
Project Plan	Form and Instruction
Form 8: Health Center Agreements	Form and Instruction
Form 6B: Request for Waiver of Board Member Requirements	Form and Instruction
Form 6A: Current Board Member Characteristics	Form and Instruction
Form 5C: Other Activities/Locations	Form and Instruction
Form 5B: Sites	Form and Instruction
Form 5A: Services Provided	Form and Instruction
Form 4: Community Characteristics	Form and Instruction
Form 4: Community Characteristics	Form and Instruction
Form 3: Income Analysis	Form and Instruction
Form 2: Staffing Profile	Form and Instruction
Form 1C: Documents on File	Form and Instruction
Form 1B: BPHC Funding Request Summary	Form and Instruction

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202603-0915-004	Revision of a currently approved collection	2026-04-23
202505-0915-002	No material or nonsubstantive change to a currently approved collection	2025-05-21
202411-0915-001	No material or nonsubstantive change to a currently approved collection	2024-11-26	Approved without change
202301-0915-005	Revision of a currently approved collection	2023-02-08	Approved without change
202011-0915-002	No material or nonsubstantive change to a currently approved collection	2020-11-30	Approved without change
202005-0915-003	No material or nonsubstantive change to a currently approved collection	2020-05-26	Approved with change
202001-0915-001	Revision of a currently approved collection	2020-01-09	Approved with change
201608-0915-003	Revision of a currently approved collection	2016-08-16	Approved with change
201410-0915-001	No material or nonsubstantive change to a currently approved collection	2014-10-09	Approved without change
201312-0915-005	No material or nonsubstantive change to a currently approved collection	2013-12-20	Approved without change
201307-0915-005	Revision of a currently approved collection	2013-07-22	Approved with change
201010-0915-006	No material or nonsubstantive change to a currently approved collection	2010-10-29	Approved without change
201007-0915-001	Revision of a currently approved collection	2010-07-01	Approved without change
200706-0915-005	Extension without change of a currently approved collection	2007-06-20	Approved without change
200402-0915-001	Existing collection in use without an OMB Control Number	2004-02-19	Approved with change

OMB Details

Form 1B: BPHC Funding Request Summary

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
Form	Name	Electronic access	Type
Form 10	2026 Form 1B: Funding Request Summary	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.