# Agency Information Collection Activities: Submission for OMB Review; Comment Request > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/fr%3A2010-14108 ## Record - **Collection:** Federal Register - **Document type:** Notice - **Published:** June 11, 2010 - **Citation:** 75 FR 33310 ## Text 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 --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/fr%3A2010-14108. Public record. Not legal advice.