2013-10377. Agency Information Collection Activities: Proposed Collection: Comment Request

ACTION:

Notice.

SUMMARY:

In compliance with the requirement for opportunity for public comment on proposed data collection projects (Section 3506(c)(2)(A) of Title 44, United States Code, as amended by the Paperwork Reduction Act of 1995, Pub. L. 104-13), the Health Resources and Services Administration (HRSA) publishes periodic summaries of proposed projects being developed for submission to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995. To request more information on the proposed project or to obtain a copy of the data collection plans and draft instruments, email [e-mail] or call the HRSA Reports Clearance Officer at [phone].

HRSA especially 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.

Information Collection Request Title: Health Center Program Application Forms: (OMB No. 0915-0285 Revision).

Abstract: Health centers (section 330 grant funded and Federally Qualified Health Center Look-Alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. Health centers have become an essential primary care provider for America's most vulnerable populations. Health centers advance the preventive and primary medical/health care home model of coordinated, comprehensive, and patient-centered care, coordinating a wide range of medical, dental, behavioral, and social services. More than 1,200 health centers operate nearly 9,000 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 Centers Program is administered by HRSA's Bureau of Primary Health Care (BPHC). HRSA/BPHC uses the following application forms to oversee the Health Center Program. These application forms are used by new and existing Health centers to apply for various grant and non-grant opportunities, renew their grant or non-grant designation, and change their scope of project.

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 Information Collection Request are summarized in the table below.

The annual estimate of burden is as follows:

Type of application form	Number of respondents	Number of responses per respondent	Total responses	Average burden per response (in hours)	Total burden hours
Form 1A: General Information Worksheet	1,350	1	1,350	2.0	2,700
Planning Grant: General Information Worksheet	250	1	250	2.5	625
Form 1B: BPHC Funding Request Summary	1,200	1	1,350	2.0	2,700
Form 1C: Documents on File	1,350	1	1,350	1.0	1,350
Form 2: Proposed Staff Profile	1,350	1	1,350	2.0	2,700
Form 3: Income Analysis Form	1,200	1	1,200	5.0	6,000
Form 4: Community Characteristics	1,350	1	1,350	1.0	1,350
Health Care Plan (Competing)	800	1	800	2.0	1,600
Health Care Plan (Non-Competing)	550	1	550	1.0	550
Business Plan (Competing)	800	1	800	2.0	1,600
Business Plan (Non-Competing)	550	1	550	1.0	550
Form 5A: Services Provided	700	1	700	1.0	700
Form 5B: Sites Listing	700	1	700	1.0	700
Form 5C: Other Site Activities	700	1	700	0.5	350
Change In Scope (CIS) Site—Add Checklist	700	1	700	1.0	700
CIS Site—Delete Checklist	700	1	700	1.0	700
CIS Relocation Checklist	700	1	700	1.0	700
CIS Service—Add Checklist	700	1	700	1.0	700
CIS Service—Delete Checklist	700	1	700	1.0	700
Add New Target Population	50	1	50	1.0	50
Form 6A: Board Member Characteristics	1,350	1	1,350	1.0	1,350
Form 6B: Request for Waiver of Governance Requirements	150	1	150	1.0	150
Form 8: Health Center Affiliation Certification	250	1	250	1.0	250
Form 9: Need for Assistance	400	1	400	3.0	1,200
Form 10: Emergency Preparedness Form	1,350	1	1,350	1.0	1,350
Form 12: Organization Points of Contact	1,350	1	1,350	0.5	675
EHR Readiness Checklist	250	1	250	1.0	250
Environmental Information and Documentation (EID)	400	1	400	2.0	800
Assurances	900	1	900	.5	450
Equipment List	400	1	400	1.0	400
Other Requirements for Sites	400	1	400	.5	200
Project Work Plan	400	1	400	1.0	400
Summary Page	400	1	400	.5	200
Verification Check List	200	1	200	.5	100
Alteration/Renovation (A/R) Project cover Page	400	1	400	1.0	400
Proposal Cover Page	400	1	400	1.0	400
Consolidated Budget	400	1	400	.5	200
Consolidated Funding Sources	400	1	400	1.0	400
Project Qualification Criteria	400	1	400	1.0	400
Project Cover Page	400	1	400	.5	200
Other Project Document	400	1	400	1.0	400
Funding Sources	400	1	400	.5	200
Total	1,350	1	27,950		37,400

ADDRESSES:

Submit your comments to [e-mail] or mail the HRSA Reports Clearance Officer, Room 10-29, Parklawn Building, 5600 Fishers Lane, Rockville, MD 20857.

DATES:

Deadline: Comments on this Information Collection Request must be received within 60 days of this notice.

Dated: April 26, 2013.

Bahar Niakan,

Director, Division of Policy and Information Coordination.