Form 5B: Service Sites

The Health Center Program Application Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0285 can be found here:

Documents and Forms

Document Name Document Type
Form 21 Form 5B: Service Sites Form and Instruction
21 Form 5B - clean.docx Form 5B - clean.docx Form and Instruction
21E Form 5B - edits.docx Form 5B - edits.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Form 5B: Service Sites	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	21	Form 5B - clean.docx	Form 5B - clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	21E	Form 5B - edits.docx	Form 5B - edits.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,508	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,508	1,508
Annual IC Time Burden (Hours)	1,508	1,508
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.