Agency Information Collection Activities: Proposed Collection: Comment Request

Federal RegisterMay 2, 2013

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

Agency Information Collection Activities: Proposed Collection: Comment Request

ACTION:

Notice.

SUMMARY:

In compliance with the requirement for opportunity for public comment on proposed data collection projects (Section 3506(c)(2)(A) of Title 44, United States Code, as amended by the Paperwork Reduction Act of 1995, Pub. L. 104-13), the Health Resources and Services Administration (HRSA) publishes periodic summaries of proposed projects being developed for submission to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995. To request more information on the proposed project or to obtain a copy of the data collection plans and draft instruments, email

paperwork@hrsa.gov

or call the HRSA Reports Clearance Officer at (301) 443-1984.

HRSA especially requests comments on: (1) The necessity and utility of the proposed information collection for the proper performance of the agency's

functions, (2) the accuracy of the estimated burden, (3) ways to enhance the quality, utility, and clarity of the information to be collected, and (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden.

Information Collection Request Title:

Health Center Program Application Forms: (OMB No. 0915-0285 Revision).

Abstract:

Health centers (section 330 grant funded and Federally Qualified Health Center Look-Alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. Health centers have become an essential primary care provider for America's most vulnerable populations. Health centers advance the preventive and primary medical/health care home model of coordinated, comprehensive, and patient-centered care, coordinating a wide range of medical, dental, behavioral, and social services. More than 1,200 health centers operate nearly 9,000 service delivery sites that provide care in every state, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Pacific Basin.

The Health Centers Program is administered by HRSA's Bureau of Primary Health Care (BPHC). HRSA/BPHC uses the following application forms to oversee the Health Center Program. These application forms are used by new and existing Health centers to apply for various grant and non-grant opportunities, renew their grant or non-grant designation, and change their scope of project.

Burden Statement:

Burden in this context means the time expended by persons to generate, maintain, retain, disclose or provide the information requested. This includes the time needed to review instructions, to develop, acquire, install and utilize technology and systems for the purpose of collecting, validating and verifying information, processing and maintaining information, and disclosing and providing information, to train personnel and to be able to respond to a collection of information, to search data sources, to complete and review the collection of information, and to transmit or otherwise disclose the information. The total annual burden hours estimated for this Information Collection Request are summarized in the table below.

The annual estimate of burden is as follows:

Type of application form

Number of

respondents

Number of

responses per

respondent

Total

responses

Average

burden per

response

(in hours)

Total burden hours

Form 1A: General Information Worksheet

1,350

2.0

2,700

Planning Grant: General Information Worksheet

250

2.5

625

Form 1B: BPHC Funding Request Summary

1,200

1,350

2.0

2,700

Form 1C: Documents on File

1,350

1.0

1,350

Form 2: Proposed Staff Profile

1,350

2.0

2,700

Form 3: Income Analysis Form

1,200

5.0

6,000

Form 4: Community Characteristics

1,350

1.0

1,350

Health Care Plan (Competing)

800

2.0

1,600

Health Care Plan (Non-Competing)

550

1.0

550

Business Plan (Competing)

800

2.0

1,600

Business Plan (Non-Competing)

550

1.0

550

Form 5A: Services Provided

700

1.0

700

Form 5B: Sites Listing

700

1.0

700

Form 5C: Other Site Activities

700

0.5

350

Change In Scope (CIS) Site—Add Checklist

700

1.0

700

CIS Site—Delete Checklist

700

1.0

700

CIS Relocation Checklist

700

1.0

700

CIS Service—Add Checklist

700

1.0

700

CIS Service—Delete Checklist

700

1.0

700

Add New Target Population

1.0

Form 6A: Board Member Characteristics

1,350

1.0

1,350

Form 6B: Request for Waiver of Governance Requirements

150

1.0

150

Form 8: Health Center Affiliation Certification

250

1.0

250

Form 9: Need for Assistance

400

3.0

1,200

Form 10: Emergency Preparedness Form

1,350

1.0

1,350

Form 12: Organization Points of Contact

1,350

0.5

675

EHR Readiness Checklist

250

1.0

250

Environmental Information and Documentation (EID)

400

2.0

800

Assurances

900

450

Equipment List

400

1.0

400

Other Requirements for Sites

400

200

Project Work Plan

400

1.0

400

Summary Page

400

200

Verification Check List

200

100

Alteration/Renovation (A/R) Project cover Page

400

1.0

400

Proposal Cover Page

400

1.0

400

Consolidated Budget

400

200

Consolidated Funding Sources

400

1.0

400

Project Qualification Criteria

400

1.0

400

Project Cover Page

400

200