The Health Center Program Application Forms

Forms and Documents

Document Name	Status
Form 0285-1a The Health Center Program Application Forms Form	Modified
Form 0285-Other Reqs The Health Center Program Application Forms Form	Modified
Form 0285-Equipment lis The Health Center Program Application Forms Form	Modified
Form 0285- Assurances The Health Center Program Application Forms Form	Modified
Form 0285-Project Impac The Health Center Program Application Forms Form	Modified
Form 0285-Project Cover The Health Center Program Application Forms Form	Modified
Form 0285-Proposal Cove The Health Center Program Application Forms Form	Modified
Form 0285-Delete Servic The Health Center Program Application Forms Form	Modified
Form 0285-Add Services The Health Center Program Application Forms Form	Modified
Form 0285-Relocate Site The Health Center Program Application Forms Form	Modified
Form 0285-Delete Site C The Health Center Program Application Forms Form	Modified
Form 0285-Add Site Chec The Health Center Program Application Forms Form	Modified
Form 0285-Business Plan The Health Center Program Application Forms Form	Modified
Form 0285-Business Plan The Health Center Program Application Forms Form	Modified
Form 0285-12 The Health Center Program Application Forms Form	Modified
Form 0285-HC Plan-SAC N The Health Center Program Application Forms Form	Modified
Form 0285-10 The Health Center Program Application Forms Form	Modified
Form 0285-8 The Health Center Program Application Forms Form	Modified
Form 0285- HC Plan- BPR The Health Center Program Application Forms Form	Modified
Form 0285-6b The Health Center Program Application Forms Form	Modified
Form 0285-6a The Health Center Program Application Forms Form	Modified
Form 0285-5c The Health Center Program Application Forms Form	Modified
Form 0285-5b The Health Center Program Application Forms Form	Modified
Form 0285-5a The Health Center Program Application Forms Form	Modified
Form 0285-4 The Health Center Program Application Forms Form	Modified
Form 0285-3 The Health Center Program Application Forms Form	Modified
Form 0285-2 The Health Center Program Application Forms Form	Modified
Form 0285-4 The Health Center Program Application Forms Form	Modified
Form 0285-1b The Health Center Program Application Forms Form	Modified
Form 0285-1a The Health Center Program Application Forms Form	Modified
Memo for nonsubstantive change.doc Justification for No Material/Nonsubstantive Change	2010-10-25
0285 nfa resource guide.doc Supplementary Document	2007-06-15
FORM 1A instructions.doc Supplementary Document	2010-06-14

IC Document Collections

IC ID	Document Title	Status
6538	The Health Center Program Application Forms Form	Modified
193532	The Health Center Program Application Forms Form	Modified
193531	The Health Center Program Application Forms Form	Modified
193530	The Health Center Program Application Forms Form	Modified
193529	The Health Center Program Application Forms Form	Modified
193528	The Health Center Program Application Forms Form	Modified
193527	The Health Center Program Application Forms Form	Modified
193526	The Health Center Program Application Forms Form	Modified
193525	The Health Center Program Application Forms Form	Modified
193524	The Health Center Program Application Forms Form	Modified
193523	The Health Center Program Application Forms Form	Modified
193522	The Health Center Program Application Forms Form	Modified
193521	The Health Center Program Application Forms Form	Modified
193520	The Health Center Program Application Forms Form	Modified
180786	The Health Center Program Application Forms Form	Modified
180785	The Health Center Program Application Forms Form	Modified
180784	The Health Center Program Application Forms Form	Modified
180783	The Health Center Program Application Forms Instruction	Modified
180782	The Health Center Program Application Forms Form	Modified
180781	The Health Center Program Application Forms Form	Modified
180780	The Health Center Program Application Forms Form	Modified
180779	The Health Center Program Application Forms Form	Modified
180778	The Health Center Program Application Forms Form	Modified
180777	The Health Center Program Application Forms Form	Modified
180776	The Health Center Program Application Forms Form	Modified
180775	The Health Center Program Application Forms Form	Modified
180774	The Health Center Program Application Forms Form	Modified
180773	The Health Center Program Application Forms Form	Modified
180772	The Health Center Program Application Forms Form	Modified
180771	The Health Center Program Application Forms Form	Modified
180770	The Health Center Program Application Forms Form	Modified

ICR Details

OMB Control No: 0915-0285	ICR Reference No: 201010-0915-006
Status: Historical Active	Previous ICR Reference No: 201007-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: The Health Center Program Application Forms
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/14/2010
	Date Received in OIRA: 10/29/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	10/31/2013	10/31/2013
Responses	22,758	0	22,758
Time Burden (Hours)	37,139	0	37,139
Cost Burden (Dollars)	0	0	0

---

Abstract: This ICR contains revisions to forms that are used by Health Centers to request support for several programs under Section 330 of the Public Health Service Act. These forms provide HRSA with information that is required in order to make appropriate funding decisions. The Health Centers apply for one or more of the listed funding opportunities based on their eligibility.

---

Authorizing Statute(s): PL: Pub.L. 107 - 251 101 Name of Law: Health Centers
   US Code: 42 USC 254b Name of Law: Health Centers
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 31

IC Title	Form No.	Form Name
The Health Center Program Application Forms	0285-12	Points of Contact
The Health Center Program Application Forms	0285-1a	General Info Worksheet
The Health Center Program Application Forms	0285-1a	Planning Grant-General Info Worksheet
The Health Center Program Application Forms	0285-1b	Funding Request Summary
The Health Center Program Application Forms	0285-HC Plan-SAC NAP	Health Care Plan- Competing
The Health Center Program Application Forms	0285-Business Plan-SAC NAP	Business Plan- SAC NAP
The Health Center Program Application Forms	0285-Relocate Site	CIS-Relocation Site Checklist
The Health Center Program Application Forms	0285-Add Services	CIS_Add Services Checklist
The Health Center Program Application Forms	0285-Business Plan-BPR	Business Plan- Non Competing
The Health Center Program Application Forms	0285-Add Site Checklist	CIS Add Site Checklist
The Health Center Program Application Forms	0285-Delete Site Checklist	CIS Delete Site Checklist
The Health Center Program Application Forms	0285-Delete Services	CIS_Delete Services Checklist
The Health Center Program Application Forms	0285-4	Documents on File
The Health Center Program Application Forms	0285-2	Staffing Profile
The Health Center Program Application Forms	0285-3	Income Analysis Form
The Health Center Program Application Forms	0285-4	Community Characteristics
The Health Center Program Application Forms	0285-5a	Services Provided
The Health Center Program Application Forms	0285-Equipment list	Equipment List
The Health Center Program Application Forms	0285-Other Reqs	Other Requirements for Sites
The Health Center Program Application Forms	0285-5b	Service Sites Listing
The Health Center Program Application Forms	0285-5c	Other Activities
The Health Center Program Application Forms	0285-6a	Board Member Characteristics
The Health Center Program Application Forms	0285-6b	Request for Waiver of Governance Requirements
The Health Center Program Application Forms	0285- HC Plan- BPR	Health Care Plan- Non Competing
The Health Center Program Application Forms	0285-8	Health Center Affiliation Certification
The Health Center Program Application Forms	0285-9	Need for Assistance
The Health Center Program Application Forms	0285-10	Annual Emergency Preparedness
The Health Center Program Application Forms	0285-Proposal Cover Pg	Capital Improvement_Investment Proposal Cover Page
The Health Center Program Application Forms	0285-Project Cover	Capital Improvement_Investment Project Cover
The Health Center Program Application Forms	0285-Project Impact	Capital Improvement_Investment Project Impact
The Health Center Program Application Forms	0285- Assurances	Assurances

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	22,758	22,758	0	0	0	0
Annual Time Burden (Hours)	37,139	37,139	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $138,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/29/2010

---