2013-16604. Agency Information Collection Activities; Submission to OMB for Review and Approval; Public Comment Request

AGENCY:

Health Resources and Services Administration, HHS.

ACTION:

Notice.

SUMMARY:

In compliance with Section 3507(a)(1)(D) of the Paperwork Reduction Act of 1995, the Health Resources and Services Administration (HRSA) has submitted an Information Collection Request (ICR) to the Office of Management and Budget (OMB) for review and approval. Comments submitted during the first public review of this ICR will be provided to OMB. OMB will accept further comments from the public during the review and approval period.

DATES:

Comments on this ICR should be received within 30 days of this notice.

ADDRESSES:

Submit your comments, including the Information Collection Request Title, to the desk officer for HRSA, either by email to [e-mail] or by fax to 202-395-5806.

FOR FURTHER INFORMATION CONTACT:

To request a copy of the clearance requests submitted to OMB for review, email the HRSA Information Collection Clearance Officer at [e-mail] or call [phone].

SUPPLEMENTARY INFORMATION:

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 ICR are summarized in the table below.

Total Estimated Annualized Burden—Hours

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	1,700	1	1,700	2.0	3,400
Form 1B: BPHC Funding Request Summary	400	1	400	1.0	400
Form 1C: Documents on File	650	1	650	1.0	650
Form 2: Staffing Profile	1,600	1	1,600	2.0	3,200
Form 3: Income Analysis	1,600	1	1,600	3.0	4,800
Form 4: Community Characteristics	650	1	650	1.0	650
Form 5A: Services Provided	1,600	1	1,600	1.0	1,600
Form 5B: Service Sites	1,600	1	1,600	1.0	1,600
Form 5C: Other Activities/Locations	1,600	1	1,600	0.5	800
Form 6A: Current Board Member Characteristics	1,600	1	1,600	1.0	1,600
Form 6B: Request for Waiver of Governance Requirements	150	1	150	1.0	150
Form 8: Health Center Agreements	250	1	250	1.0	250
Form 9: Need for Assistance Worksheet	650	1	650	5.0	3,250
Form 10: Annual Emergency Preparedness Report	1,600	1	1,600	1.0	1,600
Form 12: Organization Contacts	1,600	1	1,600	0.5	800
Clinical Performance Measures	1,600	1	1,600	2	3,200
Financial Performance Measures	1,600	1	1,600	1	1,600
Checklist for Adding a New Service Delivery Site	700	1	700	2.0	1,400
Checklist for Deleting Existing Service Delivery Site	700	1	700	2.0	1,400
Checklist for Adding New Service	700	1	700	2.0	1,400
Checklist for Deleting Existing Service	700	1	700	2.0	1,400
Checklist for Replacing Existing Service Delivery Site	700	1	700	2.0	1,400
Proposal Cover Page	400	1	400	1.0	400
Project Cover Page	400	1	400	1.0	400
Equipment List	400	1	400	1.0	400
Other Requirements for Sites	400	1	400	0.5	200
Checklist for Adding a New Target Population	50	1	50	1.0	50
Increased Demand for Services	1,200	1	1,200	1	1,200
Funding Sources	400	1	400	0.5	200
Project Qualification Criteria	400	1	400	1.0	400
Implementation Plan	400	1	400	3.0	1,200
Project Work Plan	100	1	100	4.0	400
Verification Checklist	200	1	200	0.5	100
EHR Readiness Checklist	50	1	50	0.5	25
Look Alike Budget	100	1	100	1.0	100
O&E Supplemental	1,200	1	1,200	1.0	1,200
O&E Progress Report	1,200	1	1,200	1.0	1,200
Total	30,850		30,850		44,025

Dated: July 3, 2013.

Bahar Niakan,

Director, Division of Policy and Information Coordination.