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Agency Information Collection Activities: Submission to OMB for Review and Approval; Public Comment Request; Health Center Program Application Forms

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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 no later than September 12, 2016.


Submit your comments, including the ICR 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 (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 are an essential primary care provider for America's most vulnerable populations. Health centers provide Start Printed Page 53490coordinated, comprehensive, and patient-centered primary and preventive health care. Nearly 1,400 health centers operate more than 9,800 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). BPHC uses multiple Health Center Program-specific forms (see table below) to oversee the Health Center Program.

Need and Proposed Use of the Information: 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, 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 significant 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, Outreach and Enrollment Progress Report) 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 Expanded Services). HRSA also intends to add seven 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 will require applicant confirmation that the information provided is accurate. Two of these new forms will include the Program Narrative Update, used to report progress for 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. An additional new form, Zika Progress Report, will collect quarterly progress on Zika-related projects.

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 ICR 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: 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: Emergency Preparedness Report1,00011,0001.01,000
Form 12: Organization Contacts1,00011,0000.5500
Clinical Performance Measures1,00011,0003.53,500
Financial Performance Measures1,00011,0001.01,000
Implementation Plan90019003.02,700
Project Work Plan20012005.01,000
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 Site70017001.51,050
Checklist for Deleting Existing Service Delivery Site70017001.0700
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Checklist for Adding New Service70017001.0700
Checklist for Deleting Existing Service70017001.0700
Checklist for Adding a New Target Population501500.525
Expanded Services1,40011,4001.01,400
Federal Object Class Categories1,40011,4000.25350
Supplemental Information (NEW)2,00012,0000.51,000
Summary Page (NEW)1,70011,7000.25425
Program Narrative Update (NEW)90019004.03,600
Substance Abuse Progress Report (NEW)30041,2001.01,200
Health Center Controlled Networks Progress Report (NEW)93193252,325
Health Center Controlled Networks Work Plan (NEW)931935.0465
Zika Progress Report (NEW)204801.080
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Jason E. Bennett,

Director, Division of the Executive Secretariat.

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[FR Doc. 2016-19301 Filed 8-11-16; 8:45 am]