2016-19301. Agency Information Collection Activities: Submission to OMB for Review and Approval; Public Comment Request; Health Center Program Application Forms

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 no later than September 12, 2016.

ADDRESSES:

Submit your comments, including the ICR 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 (those entities funded under Public Health Service Act section 330 and Health Center Program look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. Health centers are an essential primary care provider for America's most vulnerable populations. Health centers provide coordinated, comprehensive, and patient-centered primary and preventive health care. Nearly 1,400 health centers operate more than 9,800 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 Center Program is administered by HRSA's Bureau of Primary Health Care (BPHC). BPHC uses multiple Health Center Program-specific forms (see table below) to oversee the Health Center Program.

Need and Proposed Use of the Information: Health Center Program-specific forms are critical to Health Center Program grant and non-grant award processes and for Health Center Program oversight. The purpose of these forms is to provide HRSA staff and objective review committee panels information essential for application evaluation, funding recommendation, approval, designation, and monitoring. These forms also provide HRSA staff with information essential for ensuring compliance with Health Center Program legislative and regulatory requirements. These application forms are used by existing health centers and other organizations to apply for various grant and non-grant opportunities, renew their grant or non-grant designation, and change their scope of project.

Most of the Health Center Program-specific forms do not require any significant changes with this revision. HRSA intends to revise some of the forms to streamline and clarify data already being requested (Form 1A, 1B, 2, 3, 5A, 5B, 6A, 8, Performance Measures, Project Work Plan, Outreach and Enrollment Progress Report) and change several form names (changing Form 3A to Look-Alike Budget Information, Form 10 to Emergency Preparedness Report, and Increased Demand for Services to Expanded Services). HRSA also intends to add seven new forms. The Supplemental Information form and Summary Page will consolidate important application information that is usually found distributed throughout the application, including eligibility criteria and projected goals. These forms will require applicant confirmation that the information provided is accurate. Two of these new forms will include the Program Narrative Update, used to report progress for renewal of Health Center Program awards, and the Substance Abuse Progress Report, used to report quarterly progress for award recipients of Substance Abuse Expansion supplemental funding. Two other forms, the Health Center Controlled Networks Work Plan and Progress Report, are forms that have been used in the past (under another OMB control number) to collect application baseline data and progress metrics for grantees. An additional new form, Zika Progress Report, will collect quarterly progress on Zika-related projects.

Likely Respondents: Health Center Program award recipients and 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 name	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	1.0	1,700
Form 1B: BPHC Funding Request Summary	450	1	450	0.75	337.5
Form 1C: Documents on File	1,000	1	1,000	0.5	500
Form 2: Staffing Profile	1,700	1	1,700	1.0	1,700
Form 3: Income Analysis	1,900	1	1,900	2.5	4,750
Form 3A: Look-Alike Budget Information	100	1	100	1.0	100
Form 4: Community Characteristics	1,000	1	1,000	1.0	1,000
Form 5A: Services Provided	1,700	1	1,700	1.0	1,700
Form 5B: Service Sites	1,200	1	1,200	0.75	900
Form 5C: Other Activities/Locations	1,000	1	1,000	0.5	500
Form 6A: Current Board Member Characteristics	1,000	1	1,000	0.5	500
Form 6B: Request for Waiver of Governance Requirements	100	1	100	1.0	100
Form 8: Health Center Agreements	600	1	600	0.75	450
Form 9: Need for Assistance Worksheet	500	1	500	4.5	2,250
Form 10: Emergency Preparedness Report	1,000	1	1,000	1.0	1,000
Form 12: Organization Contacts	1,000	1	1,000	0.5	500
Clinical Performance Measures	1,000	1	1,000	3.5	3,500
Financial Performance Measures	1,000	1	1,000	1.0	1,000
Implementation Plan	900	1	900	3.0	2,700
Project Work Plan	200	1	200	5.0	1,000
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
Funding Sources	400	1	400	0.5	200
Project Qualification Criteria	400	1	400	1.0	400
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
Checklist for Adding a New Service Delivery Site	700	1	700	1.5	1,050
Checklist for Deleting Existing Service Delivery Site	700	1	700	1.0	700
Checklist for Adding New Service	700	1	700	1.0	700
Checklist for Deleting Existing Service	700	1	700	1.0	700
Checklist for Adding a New Target Population	50	1	50	0.5	25
Expanded Services	1,400	1	1,400	1.0	1,400
Federal Object Class Categories	1,400	1	1,400	0.25	350
Supplemental Information (NEW)	2,000	1	2,000	0.5	1,000
Summary Page (NEW)	1,700	1	1,700	0.25	425
Program Narrative Update (NEW)	900	1	900	4.0	3,600
Substance Abuse Progress Report (NEW)	300	4	1,200	1.0	1,200
Health Center Controlled Networks Progress Report (NEW)	93	1	93	25	2,325
Health Center Controlled Networks Work Plan (NEW)	93	1	93	5.0	465
Zika Progress Report (NEW)	20	4	80	1.0	80
Total	34,606		35,566		44,608

Jason E. Bennett,

Director, Division of the Executive Secretariat.