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Agency Information Collection Activities: Proposed Collection: Public Comment Request

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Health Resources and Services Administration, HHS.




In compliance with the requirement for opportunity for public comment on proposed data collection projects (Section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995), the Health Resources and Services Administration (HRSA) announces plans to submit an Information Collection Request (ICR), described below, to the Office of Management and Budget (OMB). Prior to submitting the ICR to OMB, HRSA seeks comments from the public regarding the burden estimate, below, or any other aspect of the ICR.


Comments on this Information Collection Request must be received no later than May 2, 2016.


Submit your comments to or mail the HRSA Information Collection Clearance Officer, Room 10-29, Parklawn Building, 5600 Fishers Lane, Rockville, MD 20857.

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To request more information on the proposed project or to obtain a copy of the data collection plans and draft instruments, email or call the HRSA Information Collection Clearance Officer at (301) 443-1984.

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When submitting comments or requesting information, please include the information request collection title for reference.

Information Collection Request Title: Health Center Program Application Forms OMB No. 0915-0285—Revision

Abstract: Health Centers (those entities funded under Public Health Service Act section 330 and Health Center Program 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; providing a wide range of medical, dental, behavioral, and social services. More than 1,300 health centers operate more than 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 Center 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.

Need and Proposed Use of the Information: BPHC Health Center Program-specific forms are critical to Health Center Program grant and non-grant award processes and for Health Center Program oversight. The purpose of these forms is to provide HRSA staff and objective review committee panels information essential for application evaluation, funding recommendation and approval, designation, and monitoring. These forms also provide HRSA staff with information essential for ensuring compliance with Health Center Program legislative and regulatory requirements. These application forms are used by existing health centers and other organizations to apply for various grant and non-grant opportunities, renew their grant or non-grant designation, and change their scope of project.

Most of the Health Center Program-specific forms do not require any changes with this revision. HRSA intends to revise some of the forms to streamline and clarify data already being requested (Form 1A, 1B, 2, 3, 5A, 5B, 6A, 8, Performance Measures, Project Work Plan) and change several form names (changing Form 3A to Look-Alike Budget Information, Form 10 to Emergency Preparedness Report, and Increased Demand for Services to Project Narrative). HRSA also intends to add six new forms. The Supplemental Information form and Summary Page will consolidate important application information that is usually found distributed throughout the application, including eligibility criteria and projected goals. These forms would require applicant confirmation that the information provided is accurate. Two Start Printed Page 10876additional forms would include the Program Narrative Update, used to report progress for the renewal of Health Center Program awards, and the Substance Abuse Progress Report, used to report quarterly progress for award recipients of Substance Abuse Expansion supplemental funding. Two other forms, the Health Center Controlled Networks Work Plan and Progress Report, are forms that have been used in the past (under another OMB control number) to collect application baseline data and progress metrics for grantees.

Likely Respondents: Health Center Program award recipients and look-alikes, state and national technical assistance organizations, and other organizations seeking 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 Information Collection Request are summarized in the table below.

Total Estimated Annualized Burden Hours

Form nameNumber of respondentsNumber of responses per respondentTotal responsesAverage burden per response (in hours)Total burden hours
Form 1A: General Information Worksheet1,70011,7001.01,700
Form 1B: BPHC Funding Request Summary45014500.75337.5
Form 1C: Documents on File1,00011,0000.5500
Form 2: Staffing Profile1,70011,7001.01,700
Form 3: Income Analysis1,90011,9002.54,750
Form 3A: FQHC Look-Alike Budget Information10011001.0100
Form 4: Community Characteristics1,00011,0001.01,000
Form 5A: Services Provided1,70011,7001.01,700
Form 5B: Service Sites1,20011,2000.75900
Form 5C: Other Activities/Locations1,00011,0000.5500
Form 6A: Current Board Member Characteristics1,00011,0000.5500
Form 6B: Request for Waiver of Governance Requirements10011001.0100
Form 8: Health Center Agreements60016000.75450
Form 9: Need for Assistance Worksheet50015004.52,250
Form 10: Annual Emergency Preparedness Report1,00011,0001.01,000
Form 12: Organization Contacts1,00011,0000.5500
Clinical Performance Measures1,00011,00022,000
Financial Performance Measures1,00011,00011,000
Implementation Plan90019003.02,700
Project Work Plan20012004.0800
Proposal Cover Page40014001.0400
Project Cover Page40014001.0400
Equipment List40014001.0400
Other Requirements for Sites40014000.5200
Funding Sources40014000.5200
Project Qualification Criteria40014001.0400
O&E Supplemental1,20011,2001.01,200
O&E Progress Report1,20011,2001.01,200
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
Checklist for Adding a New Target Population501501.050
Increased Demand for Services1,40011,40011,400
Supplemental Information (NEW)2,00012,0000.51,000
Summary Page (NEW)1,70011,7000.25425
Program Narrative Update (NEW)90019001900
Substance Abuse Progress Report (NEW)30041,20011,200
Health Center Controlled Networks Progress Report (NEW)93193252,325
Health Center Controlled Networks Work Plan (NEW)931935465
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HRSA specifically requests comments on (1) the necessity and utility of the proposed information collection for the proper performance of the agency's functions, (2) the accuracy of the estimated burden, (3) ways to enhance the quality, utility, and clarity of the information to be collected, and (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden.

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Jackie Painter,

Director, Division of the Executive Secretariat.

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[FR Doc. 2016-04535 Filed 3-1-16; 8:45 am]