Agency Information Collection Activities; Submission to OMB for Review and Approval; Public Comment Request

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

Agency Information Collection Activities; Submission to OMB for Review and Approval; Public Comment Request

AGENCY:

Health Resources and Services Administration, HHS.

ACTION:

Notice.

SUMMARY:

In compliance with Section 3507(a)(1)(D) of the Paperwork Reduction Act of 1995, the Health Resources and Services Administration (HRSA) has submitted an Information Collection Request (ICR) to the Office of Management and Budget (OMB) for review and approval. Comments submitted during the first public review of this ICR will be provided to OMB. OMB will accept further comments from the public during the review and approval period.

DATES:

Comments on this ICR should be received within 30 days of this notice.

ADDRESSES:

Submit your comments, including the Information Collection Request Title, to the desk officer for HRSA, either by email to

OIRA_submission@omb.eop.gov

or by fax to 202-395-5806.

FOR FURTHER INFORMATION CONTACT:

To request a copy of the clearance requests submitted to OMB for review, email the HRSA Information Collection Clearance Officer at

paperwork@hrsa.gov

or call (301) 443-1984.

SUPPLEMENTARY INFORMATION:

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 ICR are summarized in the table below.

Total Estimated Annualized Burden—Hours

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

1,700

1

1,700

2.0

3,400

Form 1B: BPHC Funding Request Summary

400

1

400

1.0

400

Form 1C: Documents on File

650

1

650

1.0

650

Form 2: Staffing Profile

1,600

1

1,600

2.0

3,200

Form 3: Income Analysis

1,600

1

1,600

3.0

4,800

Form 4: Community Characteristics

650

1

650

1.0

650

Form 5A: Services Provided

1,600

1

1,600

1.0

1,600

Form 5B: Service Sites

1,600

1

1,600

1.0

1,600

Form 5C: Other Activities/Locations

1,600

1

1,600

0.5

800

Form 6A: Current Board Member Characteristics

1,600

1

1,600

1.0

1,600

Form 6B: Request for Waiver of Governance Requirements

150

1

150

1.0

150

Form 8: Health Center Agreements

250

1

250

1.0

250

Form 9: Need for Assistance Worksheet

650

1

650

5.0

3,250

Form 10: Annual Emergency Preparedness Report

1,600

1

1,600

1.0

1,600

Form 12: Organization Contacts

1,600

1

1,600

0.5

800

Clinical Performance Measures

1,600

1

1,600

2

3,200

Financial Performance Measures

1,600

1

1,600

1

1,600

Checklist for Adding a New Service Delivery Site

700

1

700

2.0

1,400

Checklist for Deleting Existing Service Delivery Site

700

1

700

2.0

1,400

Checklist for Adding New Service

700

1

700

2.0

1,400

Checklist for Deleting Existing Service

700

1

700

2.0

1,400

Checklist for Replacing Existing Service Delivery Site

700

1

700

2.0

1,400

Proposal Cover Page

400

1

400

1.0

400

Project Cover Page

400

1

400

1.0

400

Equipment List

400

1

400

1.0

400

Other Requirements for Sites

400

1

400

0.5

200

Checklist for Adding a New Target Population

50

1

50

1.0

50

Increased Demand for Services

1,200

1

1,200

1

1,200

Funding Sources

400

1

400

0.5

200

Project Qualification Criteria

400

1

400

1.0

400

Implementation Plan

400

1

400

3.0

1,200

Project Work Plan

100

1

100

4.0

400

Verification Checklist

200

1

200

0.5

100

EHR Readiness Checklist

50

1

50

0.5

25

Look Alike Budget

100

1

100

1.0

100

O&E Supplemental

1,200

1

1,200

1.0

1,200

O&E Progress Report

1,200

1

1,200

1.0

1,200

Total

30,850

30,850

44,025

Dated: July 3, 2013.

Bahar Niakan,

Director, Division of Policy and Information Coordination.

[FR Doc. 2013-16604 Filed 7-9-13; 8:45 am]

BILLING CODE 4165-15-P