# Agency Information Collection Activities: Submission to OMB for Review and Approval; Public Comment Request; Health Center Program Application Forms > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/fr%3A2016-19301 ## Record - **Collection:** Federal Register - **Document type:** Notice - **Published:** August 12, 2016 - **Citation:** 81 FR 53489 ## 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; Health Center Program Application Forms 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 no later than September 12, 2016. ADDRESSES: Submit your comments, including the ICR 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 (those entities funded under Public Health Service Act section 330 and Health Center Program look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. Health centers are an essential primary care provider for America's most vulnerable populations. Health centers provide coordinated, comprehensive, and patient-centered primary and preventive health care. Nearly 1,400 health centers operate more than 9,800 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 Center Program is administered by HRSA's Bureau of Primary Health Care (BPHC). BPHC uses multiple Health Center Program-specific forms (see table below) to oversee the Health Center Program. Need and Proposed Use of the Information: Health Center Program-specific forms are critical to Health Center Program grant and non-grant award processes and for Health Center Program oversight. The purpose of these forms is to provide HRSA staff and objective review committee panels information essential for application evaluation, funding recommendation, approval, designation, and monitoring. These forms also provide HRSA staff with information essential for ensuring compliance with Health Center Program legislative and regulatory requirements. These application forms are used by existing health centers and other organizations to apply for various grant and non-grant opportunities, renew their grant or non-grant designation, and change their scope of project. Most of the Health Center Program-specific forms do not require any significant changes with this revision. HRSA intends to revise some of the forms to streamline and clarify data already being requested (Form 1A, 1B, 2, 3, 5A, 5B, 6A, 8, Performance Measures, Project Work Plan, Outreach and Enrollment Progress Report) and change several form names (changing Form 3A to Look-Alike Budget Information, Form 10 to Emergency Preparedness Report, and Increased Demand for Services to Expanded Services). HRSA also intends to add seven new forms. The Supplemental Information form and Summary Page will consolidate important application information that is usually found distributed throughout the application, including eligibility criteria and projected goals. These forms will require applicant confirmation that the information provided is accurate. Two of these new forms will include the Program Narrative Update, used to report progress for renewal of Health Center Program awards, and the Substance Abuse Progress Report, used to report quarterly progress for award recipients of Substance Abuse Expansion supplemental funding. Two other forms, the Health Center Controlled Networks Work Plan and Progress Report, are forms that have been used in the past (under another OMB control number) to collect application baseline data and progress metrics for grantees. An additional new form, Zika Progress Report, will collect quarterly progress on Zika-related projects. Likely Respondents: Health Center Program award recipients and look-alikes, state and national technical assistance organizations, and other organizations seeking funding. 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 Form name 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 1.0 1,700 Form 1B: BPHC Funding Request Summary 450 1 450 0.75 337.5 Form 1C: Documents on File 1,000 1 1,000 0.5 500 Form 2: Staffing Profile 1,700 1 1,700 1.0 1,700 Form 3: Income Analysis 1,900 1 1,900 2.5 4,750 Form 3A: Look-Alike Budget Information 100 1 100 1.0 100 Form 4: Community Characteristics 1,000 1 1,000 1.0 1,000 Form 5A: Services Provided 1,700 1 1,700 1.0 1,700 Form 5B: Service Sites 1,200 1 1,200 0.75 900 Form 5C: Other Activities/Locations 1,000 1 1,000 0.5 500 Form 6A: Current Board Member Characteristics 1,000 1 1,000 0.5 500 Form 6B: Request for Waiver of Governance Requirements 100 1 100 1.0 100 Form 8: Health Center Agreements 600 1 600 0.75 450 Form 9: Need for Assistance Worksheet 500 1 500 4.5 2,250 Form 10: Emergency Preparedness Report 1,000 1 1,000 1.0 1,000 Form 12: Organization Contacts 1,000 1 1,000 0.5 500 Clinical Performance Measures 1,000 1 1,000 3.5 3,500 Financial Performance Measures 1,000 1 1,000 1.0 1,000 Implementation Plan 900 1 900 3.0 2,700 Project Work Plan 200 1 200 5.0 1,000 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 Funding Sources 400 1 400 0.5 200 Project Qualification Criteria 400 1 400 1.0 400 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 Checklist for Adding a New Service Delivery Site 700 1 700 1.5 1,050 Checklist for Deleting Existing Service Delivery Site 700 1 700 1.0 700 Checklist for Adding New Service 700 1 700 1.0 700 Checklist for Deleting Existing Service 700 1 700 1.0 700 Checklist for Adding a New Target Population 50 1 50 0.5 25 Expanded Services 1,400 1 1,400 1.0 1,400 Federal Object Class Categories 1,400 1 1,400 0.25 350 Supplemental Information (NEW) 2,000 1 2,000 0.5 1,000 Summary Page (NEW) 1,700 1 1,700 0.25 425 Program Narrative Update (NEW) 900 1 900 4.0 3,600 Substance Abuse Progress Report (NEW) 300 4 1,200 1.0 1,200 Health Center Controlled Networks Progress Report (NEW) 93 1 93 25 2,325 Health Center Controlled Networks Work Plan (NEW) 93 1 93 5.0 465 Zika Progress Report (NEW) 20 4 80 1.0 80 Total 34,606 35,566 44,608 Jason E. Bennett, Director, Division of the Executive Secretariat. [FR Doc. 2016-19301 Filed 8-11-16; 8:45 am] BILLING CODE 4165-15-P --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/fr%3A2016-19301. Public record. Not legal advice.