# Agency Information Collection Activities; Submission to OMB for Review and Approval; Public Comment Request > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/fr%3A2013-16604 ## Record - **Collection:** Federal Register - **Document type:** Notice - **Published:** July 10, 2013 - **Citation:** 78 FR 41406 ## Text 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 --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/fr%3A2013-16604. Public record. Not legal advice.