2010-14108. Agency Information Collection Activities: Submission for OMB Review; Comment Request

Periodically, the Health Resources and Services Administration (HRSA) publishes abstracts of information collection requests under review by the Office of Management and Budget (OMB), in compliance with the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35). To request a copy of the clearance requests submitted to OMB for review, e-mail [e-mail] or call the HRSA Reports Clearance Office on [phone].

The following request has been submitted to the Office of Management and Budget for review under the Paperwork Reduction Act of 1995:

Proposed Project: Federally Qualified Health Centers (FQHC) Application Forms: (OMB No. 0915-0285)—Revisions

HRSA's Bureau of Primary Health Care administers grants to Health Centers receiving funding under section 330 of the Public Health Service Act and has an approval process for organizations seeking to qualify as Federally Qualified Health Center (FQHC) Look Alikes. These Health Centers and FQHC Look Alikes provide preventive and primary health care services to low-income and other vulnerable populations, regardless of their ability to pay and whether or not they have health insurance. Many Health Centers and FQHC Look-Alikes offer dental, mental health and substance abuse care.

HRSA uses the following application forms to administer Section 330 Health Centers grants and the FQHC Look Alike application process. These application forms are used by new and existing Health Centers and FQHC Look-Alikes to apply for grant and non-grant opportunities, renew their grant or non-grant opportunities or change their scope of project.

Estimates of annualized reporting burden are as follows:

Type of application form	Number of respondents	Responses per respondent	Total responses	Hours per response	Total burden hours
General Information Worksheet	1,034	1	1,034	2.0	2,068
Planning Grant: General Information Worksheet	250	1	250	2.5	625
BPHC Funding Request Summary	1,034	1	1,034	2.0	2,068
Documents on File	1,034	1	1,034	1.0	1,034
Proposed Staff Profile	1,034	1	1,034	2.0	2,068
Income Analysis Form	1,034	1	1,034	5.0	5,170
Community Characteristics	1,034	1	1,034	1.0	1,034
Health Care Plan (Competing)	800	1	1,034	4.0	4,136
Health Care Plan (Non-Competing)	1,034	1	1,034	2.0	2,068
Business Plan (Competing)	800	1	1,034	4.0	4,136
Business Plan (Non-Competing)	1,034	1	1,034	2.0	2,068
Services Provided	1,034	1	1,034	1.0	1,034
Sites Listing	1,034	1	1,034	1.0	1,034
Other Site Activities	700	1	700	0.5	350
Change In Scope (CIS) Site Add Checklist	300	1	300	1.0	300
CIS Site Delete Checklist	200	1	200	1.0	200
CIS Relocation Checklist	200	1	200	1.5	300
CIS Service Add Checklist	100	1	200	1.0	200
CIS Service Delete Checklist	100	1	100	1.0	100
Board Member Characteristics	1,034	1	1,034	1.0	1,034
Request for Waiver of Governance Requirements	150	1	150	1.0	150
Health Center Affiliation Certification	250	1	250	1.0	250
Need for Assistance	900	1	900	3.0	2,700
Emergency Preparedness Form	1,034	1	1,034	1.0	1,034
Points of Contact	800	1	800	0.5	400
EHR Readiness Checklist	250	1	250	1.0	250
Environmental Information and Documentation (EID)	400	1	400	2.0	800
Capital Improvement/Investment Proposal Cover Page	700	1	700	1.0	700
Assurances	900	1	900	.5	450
Capital Improvement/Investment Project Cover	700	1	700	1.0	700
Capital Improvement/Investment Project Impact	700	1	700	.5	350
Equipment List	900	1	900	1.0	900
Other Requirements for Sites	900	1	900	.5	450
Total	1,138	1	23,976		40,161

Written comments and recommendations concerning the proposed information collection should be sent within 30 days of this notice to the desk officer for HRSA, either by email to [e-mail] or by fax to 202-395-6974. Please direct all correspondence to the “attention of the desk officer for HRSA.”

Dated: June 7, 2010.

Sahira Rafiullah,

Director, Division of Policy and Information Coordination.