Skip to Content


Agency Information Collection Activities: Submission for OMB Review; 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

Periodically, the Health Resources and Services Administration (HRSA) publishes abstracts of information collection requests under review by the Office of Management and Budget (OMB), in compliance with the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35). To request a copy of the clearance requests submitted to OMB for review, e-mail or call the HRSA Reports Clearance Office on (301) 443-1129.

The following request has been submitted to the Office of Management and Budget for review under the Paperwork Reduction Act of 1995:

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

HRSA's Bureau of Primary Health Care administers grants to Health Centers receiving funding under section 330 of the Public Health Service Act and has an approval process for organizations seeking to qualify as Federally Qualified Health Center (FQHC) Look Alikes. These Health Centers and FQHC Look Alikes provide preventive and primary health care services to low-income and other vulnerable populations, regardless of their ability to pay and whether or not they have health insurance. Many Health Centers and FQHC Look-Alikes offer dental, mental health and substance abuse care.

HRSA uses the following application forms to administer Section 330 Health Centers grants and the FQHC Look Alike application process. These application forms are used by new and existing Health Centers and FQHC Look-Alikes 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:

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
Start Printed Page 33311
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
Capital Improvement/Investment Proposal Cover Page70017001.0700
Capital Improvement/Investment Project Cover70017001.0700
Capital Improvement/Investment Project Impact7001700.5350
Equipment List90019001.0900
Other Requirements for Sites9001900.5450

Written comments and recommendations concerning the proposed information collection should be sent within 30 days of this notice to the desk officer for HRSA, either by email to or by fax to 202-395-6974. Please direct all correspondence to the “attention of the desk officer for HRSA.”

Start Signature

Dated: June 7, 2010.

Sahira Rafiullah,

Director, Division of Policy and Information Coordination.

End Signature End Preamble

[FR Doc. 2010-14108 Filed 6-10-10; 8:45 am]