2019-06766. Agency Information Collection Activities: Proposed Collection: Public Comment Request: Information Collection Request Title: Health Center Program Forms, OMB No. 0915-0285-Revision  

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    Health Resources and Services Administration (HRSA), Department of Health and Human Services.




    In compliance with the requirement for opportunity for public comment on proposed data collection projects of the Paperwork Reduction Act of 1995, 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 ICR should be received no later than June 7, 2019.


    Submit your comments to paperwork@hrsa.gov or mail the HRSA Information Collection Clearance Officer, Room 14N136B, 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 paperwork@hrsa.gov or call Lisa Wright-Solomon, 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 Forms; OMB No. 0915-0285—Revision.

    Abstract: The Health Center Program, administered by HRSA, is authorized under section 330 of the Public Health Service (PHS) Act, most recently amended by section 50901(b) of the Bipartisan Budget Act of 2018, Public Law 115-123. Health centers are community-based and patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients regardless of their ability to pay. Nearly 1,400 health centers operate approximately 12,000 service delivery sites that provide primary health care to more than 27 million people in every U.S. state, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Pacific Basin. HRSA utilizes forms for new and existing health centers and other entities to apply for various grant and non-grant opportunities, renew grant and non-grant designations, report progress, and change their scopes of project.

    Need and Proposed Use of the Information: Health Center Program-specific forms are necessary for Health Center Program award processes and oversight. These forms provide HRSA staff and objective review committee panels with information essential for application evaluation, funding recommendation and approval, designation, and monitoring. These forms also provide HRSA staff with information essential for evaluating compliance with Health Center Program legislative and regulatory requirements.

    HRSA intends to make the following changes to its forms:

    • Modify the following forms to streamline and clarify data currently being collected: 1A, 1C, 2, 3, 3A, 4, 5A, 5C, 6A, 8, 12, Health Center Controlled Networks (HCCN) Progress Report, Program Specific Forms Instructions, Project Narrative Update (Budget Period Progress Report [BPR]), Project Work Plan, and the Summary Page.
    • Rename Substance Abuse Progress Report to Health Center Program Progress Report.
    • Add the following forms necessary for funding applications and program monitoring: Capital Semi-Annual Progress Report, HCCN Participating Health Center List, Loan Guarantee Application, Patient Target Question Verification, Project Plan, and Substance Use Disorder and Mental Health Services (SUD-MH) Supplemental Funding Progress Report.
    • Remove the following forms to further streamline information collected by HRSA and reduce burden: Alterations and Renovations Project Cover Page, Form 9: Need for Assistance, Form 10: Annual Emergency Preparedness Report, HCCN Work Plan, Outreach and Enrollment Supplemental, and Zika Progress Report.

    Likely Respondents: Health Center Program award recipients (those funded under section 330 of the PHS Act) and Health Center Program 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
    Capital Semi-Annual Progress Report (New)99619961.00996
    Checklist for Adding a New Service45014501.00450
    Checklist for Adding a New Service Delivery Site1,48011,4801.502,220
    Checklist for Adding a New Target Population10011000.5050
    Checklist for Deleting an Existing Service50015001.00500
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    Checklist for Deleting an Existing Service Delivery Site50015001.00500
    Clinical Performance Measures1,05811,0583.503,703
    Equipment List1,37511,3751.001,375
    Expanded Services Project Narrative)1,05811,0581.001,058
    Federal Object Class Categories73517350.25184
    Financial Performance Measures1,05811,0581.001,058
    Form 1A: General Information Worksheet1,05811,0581.001,058
    Form 1B: BPHC Funding Request Summary1,00011,0000.75750
    Form 1C: Documents on File1,05811,0580.50529
    Form 2: Staffing Profile1,05811,0581.001,058
    Form 3: Income Analysis1,05811,0582.502,645
    Form 3A: Look-Alike Budget Information501501.0050
    Form 4: Community Characteristics1,05811,0581.001,058
    Form 5A: Services Provided1,05811,0581.001,058
    Form 5B: Service Sites1,50811,5080.751,131
    Form 5C: Other Activities/Locations1,05811,0580.50529
    Form 6A: Current Board Member Characteristics1,05811,0580.50529
    Form 6B: Request for Waiver of Governance Requirements1,05811,0581.001,058
    Form 8: Health Center Agreements1,05811,0580.75794
    Form 12: Organization Contacts1,05811,0580.50529
    Funding Sources73517350.50368
    HCCN Participating Health Center List (NEW)901901.0090
    HCCN Progress Report9019025.002,250
    Health Center Program Progress Report (previously Substance Abuse Progress Report)73517351.00735
    Loan Guarantee Application (NEW)201201.0020
    Operational Plan Instructions50015003.001,500
    Other Requirements for Sites60016000.50300
    Patient Target Question Verification (NEW)1,05811,0581.001,058
    Program Specific Form Instructions1,50011,5001.001,500
    Project Cover Page73517351.00735
    Project Narrative Update (BPR)88318834.003,532
    Project Plan (NEW)1,30011,3001.001,300
    Project Qualification Criteria73517351.00735
    Project Work Plan13511355.00675
    Proposal Cover Page73517351.00735
    SUD-MH Supplemental Funding Progress Report (NEW)1,37511,3751.001,375
    Summary Page1,00811,0080.25252
    Supplemental Information50015001.00500
    Total Hours35,79035,79042,530

    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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    Amy P. McNulty,

    Acting Director, Division of the Executive Secretariat.

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    [FR Doc. 2019-06766 Filed 4-5-19; 8:45 am]

    BILLING CODE 4165-15-P

Document Information

Health and Human Services Department
Health Resources and Services Administration
Document Number:
Comments on this ICR should be received no later than June 7, 2019.
13937-13938 (2 pages)
PDF File: