Application for Health Center Program Recipients for Deemed Public Health Service Employment with Liability Protections Under the Federal Tort Claims Act (FTCA)

Forms and Documents

Document Name	Status
Form 1 Application for Health Center Program Recipients for Deemed Public Health Service Employment with Liability Protections Under the Federal Tort Claims Act (FTCA) Form and Instruction	Modified
0035 FTCA Health Center Supporting Statement 3.8.22.docx Supporting Statement A	2022-03-31
FTCA Health Center Deeming PIA 02.01.18.pdf Supplementary Document	2018-03-06

IC Document Collections

IC ID	Document Title	Status
230498	Application for Health Center Program Recipients for Deemed Public Health Service Employment with Liability Protections Under the Federal Tort Claims Act (FTCA) Form and Instruction	Modified

ICR Details

OMB Control No: 0906-0035	ICR Reference No: 202203-0906-003
Status: Received in OIRA	Previous ICR Reference No: 202104-0906-002
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Application for Health Center Program Recipients for Deemed Public Health Service Employment with Liability Protections Under the Federal Tort Claims Act (FTCA)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 04/04/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2024
Responses	1,160	1,160
Time Burden (Hours)	2,900	2,900
Cost Burden (Dollars)	0	0

---

Abstract: Deemed status for FTCA medical malpractice coverage requires HRSA approval of an application for deeming. This form provides HRSA with the information essential for application evaluation and determination of whether a health center meets the statutory requirements for deemed PHS employee status for the purposes of FTCA coverage. Most respondents will be not-for-profit institutions, but some will be local government entities.

---

Authorizing Statute(s): US Code: 42 USC 233(g)-(n) Name of Law: Public Health and Welfare
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 72250	12/21/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 18371	03/30/2022
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Application for Health Center Program Recipients for Deemed Public Health Service Employment with Liability Protections Under the Federal Tort Claims Act (FTCA)	1	CY 2023 Health Center APPLICATION ONLY 3.2.22

---

ICR Summary of Burden

	Total Request	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	1,160	1,160	0	0	0	0
Annual Time Burden (Hours)	2,900	2,900	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: $189,138

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

---

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: 04/04/2022

---