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Agency Information Collection Activities; Submission to OMB for Review and Approval; Public Comment Request

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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 or by fax to 202-395-5806.

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To request a copy of the clearance requests submitted to OMB for review, email the HRSA Information Collection Clearance Officer at or call (301) 443-1984.

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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 formNumber of respondentsNumber of responses per respondentTotal responsesAverage burden per response (in hours)Total burden hours
Form 1A: General Information Worksheet1,70011,7002.03,400
Form 1B: BPHC Funding Request Summary40014001.0400
Form 1C: Documents on File65016501.0650
Form 2: Staffing Profile1,60011,6002.03,200
Form 3: Income Analysis1,60011,6003.04,800
Form 4: Community Characteristics65016501.0650
Form 5A: Services Provided1,60011,6001.01,600
Form 5B: Service Sites1,60011,6001.01,600
Form 5C: Other Activities/Locations1,60011,6000.5800
Form 6A: Current Board Member Characteristics1,60011,6001.01,600
Form 6B: Request for Waiver of Governance Requirements15011501.0150
Form 8: Health Center Agreements25012501.0250
Form 9: Need for Assistance Worksheet65016505.03,250
Form 10: Annual Emergency Preparedness Report1,60011,6001.01,600
Form 12: Organization Contacts1,60011,6000.5800
Clinical Performance Measures1,60011,60023,200
Financial Performance Measures1,60011,60011,600
Checklist for Adding a New Service Delivery Site70017002.01,400
Checklist for Deleting Existing Service Delivery Site70017002.01,400
Checklist for Adding New Service70017002.01,400
Checklist for Deleting Existing Service70017002.01,400
Checklist for Replacing Existing Service Delivery Site70017002.01,400
Proposal Cover Page40014001.0400
Project Cover Page40014001.0400
Equipment List40014001.0400
Other Requirements for Sites40014000.5200
Checklist for Adding a New Target Population501501.050
Increased Demand for Services1,20011,20011,200
Funding Sources40014000.5200
Project Qualification Criteria40014001.0400
Implementation Plan40014003.01,200
Project Work Plan10011004.0400
Verification Checklist20012000.5100
EHR Readiness Checklist501500.525
Look Alike Budget10011001.0100
O&E Supplemental1,20011,2001.01,200
O&E Progress Report1,20011,2001.01,200
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Dated: July 3, 2013.

Bahar Niakan,

Director, Division of Policy and Information Coordination.

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[FR Doc. 2013-16604 Filed 7-9-13; 8:45 am]