# Agency Information Collection Activities: Proposed Collection: Comment Request > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/fr%3A2013-10377 ## Record - **Collection:** Federal Register - **Document type:** Notice - **Published:** May 2, 2013 - **Citation:** 78 FR 25750 ## Text 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 1 1,350 2.0 2,700 Planning Grant: General Information Worksheet 250 1 250 2.5 625 Form 1B: BPHC Funding Request Summary 1,200 1 1,350 2.0 2,700 Form 1C: Documents on File 1,350 1 1,350 1.0 1,350 Form 2: Proposed Staff Profile 1,350 1 1,350 2.0 2,700 Form 3: Income Analysis Form 1,200 1 1,200 5.0 6,000 Form 4: Community Characteristics 1,350 1 1,350 1.0 1,350 Health Care Plan (Competing) 800 1 800 2.0 1,600 Health Care Plan (Non-Competing) 550 1 550 1.0 550 Business Plan (Competing) 800 1 800 2.0 1,600 Business Plan (Non-Competing) 550 1 550 1.0 550 Form 5A: Services Provided 700 1 700 1.0 700 Form 5B: Sites Listing 700 1 700 1.0 700 Form 5C: Other Site Activities 700 1 700 0.5 350 Change In Scope (CIS) Site—Add Checklist 700 1 700 1.0 700 CIS Site—Delete Checklist 700 1 700 1.0 700 CIS Relocation Checklist 700 1 700 1.0 700 CIS Service—Add Checklist 700 1 700 1.0 700 CIS Service—Delete Checklist 700 1 700 1.0 700 Add New Target Population 50 1 50 1.0 50 Form 6A: Board Member Characteristics 1,350 1 1,350 1.0 1,350 Form 6B: Request for Waiver of Governance Requirements 150 1 150 1.0 150 Form 8: Health Center Affiliation Certification 250 1 250 1.0 250 Form 9: Need for Assistance 400 1 400 3.0 1,200 Form 10: Emergency Preparedness Form 1,350 1 1,350 1.0 1,350 Form 12: Organization Points of Contact 1,350 1 1,350 0.5 675 EHR Readiness Checklist 250 1 250 1.0 250 Environmental Information and Documentation (EID) 400 1 400 2.0 800 Assurances 900 1 900 .5 450 Equipment List 400 1 400 1.0 400 Other Requirements for Sites 400 1 400 .5 200 Project Work Plan 400 1 400 1.0 400 Summary Page 400 1 400 .5 200 Verification Check List 200 1 200 .5 100 Alteration/Renovation (A/R) Project cover Page 400 1 400 1.0 400 Proposal Cover Page 400 1 400 1.0 400 Consolidated Budget 400 1 400 .5 200 Consolidated Funding Sources 400 1 400 1.0 400 Project Qualification Criteria 400 1 400 1.0 400 Project Cover Page 400 1 400 .5 200 Other Project Document 400 1 400 1.0 400 Funding Sources 400 1 400 .5 200 Total 1,350 1 27,950 37,400 ADDRESSES: Submit your comments to paperwork@hrsa.gov or mail the HRSA Reports Clearance Officer, Room 10-29, Parklawn Building, 5600 Fishers Lane, Rockville, MD 20857. DATES: Deadline: Comments on this Information Collection Request must be received within 60 days of this notice. Dated: April 26, 2013. Bahar Niakan, Director, Division of Policy and Information Coordination. [FR Doc. 2013-10377 Filed 5-1-13; 8:45 am] BILLING CODE 4165-15-P --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/fr%3A2013-10377. Public record. Not legal advice.