Skip to Content


Agency Information Collection Activities: Proposed Collection: Comment Request

Document Details

Information about this document as published in the Federal Register.

Published Document

This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.

Start Preamble

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, e-mail or call the HRSA Reports Clearance Officer at (301) 443-1129.

Comments are invited on: (a) The proposed collection of information for the proper performance of the functions of the agency; (b) the accuracy of the agency's estimate of the burden of the proposed collection of information; (c) ways to enhance the quality, utility, and clarity of the information to be collected; and (d) ways to minimize the burden of the collection of information on respondents, including through the use of automated collection techniques or other forms of information technology.

Proposed Project: Federally Qualified Health Centers (FQHC) Application Forms: (OMB No. 0915-0285 Revisions)

HRSA's Bureau of Primary Health Care Federally Qualified Health Centers (FQHCs) are a major component of America's health care safety net, the Nation's “system” of providing health care to low-income and other vulnerable populations. Health Centers care for people regardless of their ability to pay and whether or not they have health insurance. They provide primary and preventive health care, as well as services such as transportation and translation. Many Health Centers also offer dental, mental health and substance abuse care.

FQHC's are administered by the Health Resources and Services Administration's (HRSA) Bureau of Primary Health Care (BPHC). HRSA uses the following application forms to administer and manage the FQHCs. These application forms are used by new and existing FQHCs to apply for grant and non-grant opportunities, renew their grant or non-grant opportunities or change their scope of project.

Estimates of annualized reporting burden are as follows:Start Printed Page 15437

Type of application formNumber of respondentsResponses per respondentTotal responsesHours per responseTotal burden hours
General Information Worksheet1,03411,0342.02,068
Planning Grant: General Information Worksheet25012502.5625
BPHC Funding Request Summary1,03411,0342.02,068
Documents on File1,03411,0341.01,034
Proposed Staff Profile1,03411,0342.02,068
Income Analysis Form1,03411,0345.05,170
Community Characteristics1,03411,0341.01,034
Health Care Plan (Competing)80011,0344.04,136
Health Care Plan (Non-Competing)1,03411,0342.02,068
Business Plan (Competing)80011,0344.04,136
Business Plan (Non-Competing)1,03411,0342.02,068
Services Provided1,03411,0341.01,034
Sites Listing1,03411,0341.01,034
Other Site Activities70017000.5350
Change In Scope (CIS) Site Add Checklist30013001.0300
CIS Site Delete Checklist20012001.0200
CIS Relocation Checklist20012001.5300
CIS Service Add Checklist10012001.0200
CIS Service Delete Checklist10011001.0100
Board Member Characteristics1,03411,0341.01,034
Request for Waiver of Governance Requirements15011501.0150
Health Center Affiliation Certification25012501.0250
Need for Assistance90019003.02,700
Emergency Preparedness Form1,03411,0341.01,034
Points of Contact80018000.5400
EHR Readiness Checklist25012501.0250
Environmental Information and Documentation (EID)40014002.0800
Equipment List90019001.0900
Other Requirements for Sites9001900.5450

E-mail comments to or mail the HRSA Reports Clearance Officer, Room 10-33, Parklawn Building, 5600 Fishers Lane, Rockville, MD 20857. Written comments should be received within 60 days of this notice.

Start Signature

Dated: March 22,2010.

Sahira Rafiullah,

Director, Division of Policy and Information Coordination.

End Signature End Preamble

[FR Doc. 2010-6880 Filed 3-26-10; 8:45 am]