# Agency Information Collection Activities: Submission to OMB for Review and Approval; Public Comment Request; Health Center Program Forms, OMB No. 0915-0285-Revision > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/fr%3A2019-27909 ## Record - **Collection:** Federal Register - **Document type:** Notice - **Published:** December 27, 2019 - **Citation:** 84 FR 71433 ## 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 Forms, OMB No. 0915-0285—Revision AGENCY: Health Resources and Services Administration (HRSA), Department of Health and Human Services. ACTION: Notice. SUMMARY: In compliance with of the Paperwork Reduction Act of 1995, 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. OMB may act on HRSA's ICR only after the 30 day comment period for this notice has closed. DATES: Comments on this ICR should be received no later than January 27, 2020. 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 Lisa Wright-Solomon, the HRSA Information Collection Clearance Officer at paperwork@hrsa.gov or call (301) 443-1984. SUPPLEMENTARY INFORMATION: Information Collection Request Title: Health Center Program Forms OMB No. 0915-0285—Revision. Abstract: The Health Center Program, administered by HRSA, is authorized under section 330 of the Public Health Service (PHS) Act, most recently amended by section 50901(b) of the Bipartisan Budget Act of 2018, Public Law 115-123. Health centers are community-based and patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients regardless of their ability to pay. Nearly 1,400 health centers operate approximately 12,000 service delivery sites that provide primary health care to more than 27 million people in every U.S. state, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Pacific Basin. HRSA utilizes forms for new and existing health centers and other entities to apply for various grant and non-grant opportunities, renew grant and non-grant designations, report progress, and change their scopes of project. A 60-day notice was published in the Federal Register on April 8, 2019, vol. 84, No. 67; pp. 13937-38. No public comments were received. Need and Proposed Use of the Information: Health Center Program-specific forms are necessary for Health Center Program award processes and oversight. These forms provide HRSA staff and objective review committee panels with information essential for application evaluation, funding recommendation and approval, designation, and monitoring. These forms also provide HRSA staff with information essential for evaluating compliance with Health Center Program legislative and regulatory requirements. HRSA intends to make several changes to its forms: • HRSA will modify the following forms to streamline and clarify data (e.g., text changes, updated instructions) currently being collected: 1A, 1B, 1C, 2, 3, 3A, 4, 5A, 5B, 5C, 6A, 8, 12, Checklist for Adding a New Service, Checklist for Adding a New Service Delivery Site, Checklist for Adding a New Target Population, Checklist for Deleting Existing Service, Checklist for Deleting Existing Service Delivery Site, Clinical Performance Measures, Equipment List, Expanded Services, Federal Object Class Categories, Financial Performance Measures, Funding Sources, Health Center Controlled Networks (HCCN) Progress Report Table, Operational Plan, Program Specific Forms Instructions, Project Qualification Criteria, Project Work Plan, Proposal Cover Page, and the Summary Page. • HRSA will rename the following forms: Substance Abuse Progress Report will be changed to Health Center Program Progress Report, Program Narrative Update will be changed to Project Narrative Update, and Outreach and Enrollment Supplemental form will be changed to Health Center Program: Supplemental Information. • HRSA will add the following forms to collect information to support funding applications and program monitoring: Capital Semi-Annual Progress Report, Diabetes Action Plan Quarterly Report Template, FY 2018 Expanding Access to Quality Substance Use Disorder and Mental Health Services (SUD-MH)/Integrated Behavioral Health Services (IBHS) Progress Reporting, FY2020 Ending the HIV Epidemic—Primary Care HIV Prevention Progress Reporting, HRSA Electronic Handbooks Action Plan, HRSA Loan Guarantee Program Application, Participating Health Center List, Patient Target and Calculations, Project Overview, and Project Plan. • HRSA will remove the following forms to further streamline information collected by HRSA and reduce burden: Alterations and Renovations Project Cover Page, Form 9: Need for Assistance, Form 10: Annual Emergency Preparedness Report, HCCN Work Plan, and Zika Progress Report. Since the submission of the 60-day Federal Register notice (FRN), there are 5 additional new forms (for a total of 10 new forms) due to new initiatives that required clearance (2 HIV funding-related forms, 2 diabetes funding-related forms, and 1 HCCN funding-related form); the data needed for the new initiatives could not be captured in forms previously approved. Please note, the 60-day FRN included one form identified as “new” (Project Work Plan); however, that form was actually included in the previous OMB package submitted in 2017. The correction has been made in this 30-day FRN and this form is no longer listed as new in this documentation. The 60-day FRN request contained 42,530 burden hours. However, this final 30-day notice includes an additional 16,712 burden hours, for a new total of 59,242 burden hours. Likely Respondents: Health Center Program award recipients (those funded under section 330 of the PHS Act); Health Center Program look-alikes; state and national trade associations; and other organizations seeking Health Center Program 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 Capital Semi-Annual Progress Report (new) 996 2 1,992 1.00 1,992 Checklist for Adding a New Service 450 1 450 2.00 900 Checklist for Adding a New Service Delivery Site 1,480 1 1,480 2.00 2,960 Checklist for Adding a New Target Population 100 1 100 2.00 200 Checklist for Deleting Existing Service 500 1 500 2.00 1,000 Checklist for Deleting Existing Service Delivery Site 750 1 750 2.00 1,500 Clinical Performance Measures 1,058 1 1,058 3.50 3,703 Diabetes Action Plan—Quarterly Report Template (new) 1,058 4 4,232 2.00 8,464 Equipment List 1,375 1 1,375 1.00 1,375 Expanded Services 996 1 996 1.00 996 Federal Object Class Categories 735 1 735 0.25 184 Financial Performance Measures 1,058 1 1,058 1.50 1,587 Form 1A: General Information Worksheet 1,058 1 1,058 1.00 1,058 Form 1B: BPHC Funding Request Summary 1,000 1 1,000 0.75 750 Form 1C: Documents on File 1,058 1 1,058 0.50 529 Form 2: Staffing Profile 1,058 1 1,058 1.00 1,058 Form 3: Income Analysis 1,058 1 1,058 1.00 1,058 Form 3A: FQHC Look-Alike Budget Information 50 1 50 1.00 50 Form 4: Community Characteristics 1,058 1 1,058 1.00 1,058 Form 5A: Services Provided 1,058 1 1,058 1.00 1,058 Form 5B: Service Sites 1,508 1 1,508 1.00 1,508 Form 5C: Other Activities/Locations 1,058 1 1,058 0.50 529 Form 6A: Current Board Member Characteristics 1,058 1 1,058 1.00 1,058 Form 6B: Request for Waiver of Board Member Requirements 1,058 1 1,058 1.00 1,058 Form 8: Health Center Agreements 1,058 1 1,058 1.00 1,058 Form 12: Organization Contacts 1,058 1 1,058 0.50 529 Funding Sources 735 1 735 0.50 368 FY2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting (new) 1,375 3 4,125 1.00 4,125 FY2020 Ending the HIV Epidemic—Primary Care HIV Prevention Progress Reporting (new) 182 1 182 1.00 182 HCCN Progress Report Table 90 1 90 1.00 90 Health Center Program Progress Report (previously Substance Abuse Progress Report) 735 1 735 1.00 735 Health Center Program: Supplemental Information (previously Outreach and Enrollment Supplemental Form) 500 1 500 1.00 500 HRSA Electronic Handbooks Action Plan (new) 1,058 4 4,232 1.00 4,232 HRSA Loan Guarantee Program Application (new) 20 1 20 1.00 20 Operational Plan 500 1 500 3.00 1,500 Other Requirements for Sites 600 1 600 0.50 300 Participating Health Center List (new) 90 1 90 1.00 90 Patient Target and Calculations (new) 1,058 1 1,058 1.00 1,058 Program Specific Forms Instructions 1,500 1 1,500 1.00 1,500 Project Narrative Update (previously Program Narrative Update) 883 1 883 4.00 3,532 Project Overview (new) 182 1 182 1.00 182 Project Plan (new) 182 3 546 1.50 819 Project Qualification Criteria 735 1 735 1.00 735 Project Work Plan 135 1 135 4.00 540 Proposal Cover Page 735 1 735 1.00 735 Summary Page 1,558 1 1,558 0.50 779 Total Hours 37,605 48,063 59,242 Maria G. Button, Director, Executive Secretariat. [FR Doc. 2019-27909 Filed 12-26-19; 8:45 am] BILLING CODE 4165-15-P --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/fr%3A2019-27909. Public record. Not legal advice.