Health Resources and Services Administration, HHS.
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.
Comments on this ICR should be received within 30 days of this notice.
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.
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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 firstname.lastname@example.org or call (301) 443-1984.
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Start Supplemental 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 Start Printed Page 41407hours 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
(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|
|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|
|Project Qualification Criteria||400||1||400||1.0||400|
|Project Work Plan||100||1||100||4.0||400|
|EHR Readiness Checklist||50||1||50||0.5||25|
|Look Alike Budget||100||1||100||1.0||100|
|O&E Progress Report||1,200||1||1,200||1.0||1,200|
End Supplemental Information
Dated: July 3, 2013.
Director, Division of Policy and Information Coordination.
[FR Doc. 2013-16604 Filed 7-9-13; 8:45 am]
BILLING CODE 4165-15-P