Agency Information Collection Activities: Submission for OMB Review; Comment Request

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

Agency Information Collection Activities: Submission for OMB Review; Comment Request

Periodically, the Health Resources and Services Administration (HRSA) publishes abstracts of information collection requests under review by the Office of Management and Budget (OMB), in compliance with the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35). To request a copy of the clearance requests submitted to OMB for review, e-mail

paperwork@hrsa.gov

or call the HRSA Reports Clearance Office on (301) 443-1129.

The following request has been submitted to the Office of Management and Budget for review under the Paperwork Reduction Act of 1995:

Proposed Project: Federally Qualified Health Centers (FQHC) Application Forms: (OMB No. 0915-0285)—Revisions

HRSA's Bureau of Primary Health Care administers grants to Health Centers receiving funding under section 330 of the Public Health Service Act and has an approval process for organizations seeking to qualify as Federally Qualified Health Center (FQHC) Look Alikes. These Health Centers and FQHC Look Alikes provide preventive and primary health care services to low-income and other vulnerable populations, regardless of their ability to pay and whether or not they have health insurance. Many Health Centers and FQHC Look-Alikes offer dental, mental health and substance abuse care.

HRSA uses the following application forms to administer Section 330 Health Centers grants and the FQHC Look Alike application process. These application forms are used by new and existing Health Centers and FQHC Look-Alikes to apply for grant and non-grant opportunities, renew their grant or non-grant opportunities or change their scope of project.

Estimates of annualized reporting burden are as follows:

Type of application form

Number of

respondents

Responses per

respondent

Total

responses

Hours per

response

Total burden hours

General Information Worksheet

1,034

1

1,034

2.0

2,068

Planning Grant: General Information Worksheet

250

1

250

2.5

625

BPHC Funding Request Summary

1,034

1

1,034

2.0

2,068

Documents on File

1,034

1

1,034

1.0

1,034

Proposed Staff Profile

1,034

1

1,034

2.0

2,068

Income Analysis Form

1,034

1

1,034

5.0

5,170

Community Characteristics

1,034

1

1,034

1.0

1,034

Health Care Plan (Competing)

800

1

1,034

4.0

4,136

Health Care Plan (Non-Competing)

1,034

1

1,034

2.0

2,068

Business Plan (Competing)

800

1

1,034

4.0

4,136

Business Plan (Non-Competing)

1,034

1

1,034

2.0

2,068

Services Provided

1,034

1

1,034

1.0

1,034

Sites Listing

1,034

1

1,034

1.0

1,034

Other Site Activities

700

1

700

0.5

350

Change In Scope (CIS) Site Add Checklist

300

1

300

1.0

300

CIS Site Delete Checklist

200

1

200

1.0

200

CIS Relocation Checklist

200

1

200

1.5

300

CIS Service Add Checklist

100

1

200

1.0

200

CIS Service Delete Checklist

100

1

100

1.0

100

Board Member Characteristics

1,034

1

1,034

1.0

1,034

Request for Waiver of Governance Requirements

150

1

150

1.0

150

Health Center Affiliation Certification

250

1

250

1.0

250

Need for Assistance

900

1

900

3.0

2,700

Emergency Preparedness Form

1,034

1

1,034

1.0

1,034

Points of Contact

800

1

800

0.5

400

EHR Readiness Checklist

250

1

250

1.0

250

Environmental Information and Documentation (EID)

400

1

400

2.0

800

Capital Improvement/Investment Proposal Cover Page

700

1

700

1.0

700

Assurances

900

1

900

.5

450

Capital Improvement/Investment Project Cover

700

1

700

1.0

700

Capital Improvement/Investment Project Impact

700

1

700

.5

350

Equipment List

900

1

900

1.0

900

Other Requirements for Sites

900

1

900

.5

450

Total

1,138

1

23,976

40,161

Written comments and recommendations concerning the proposed information collection should be sent within 30 days of this notice to the desk officer for HRSA, either by email to

OIRA_submission@omb.eop.gov

or by fax to 202-395-6974. Please direct all correspondence to the “attention of the desk officer for HRSA.”

Dated: June 7, 2010.

Sahira Rafiullah,

Director, Division of Policy and Information Coordination.

[FR Doc. 2010-14108 Filed 6-10-10; 8:45 am]

BILLING CODE 4165-15-P