[Federal Register Volume 78, Number 132 (Wednesday, July 10, 2013)]
[Notices]
[Pages 41406-41407]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2013-16604]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Agency Information Collection Activities; Submission to OMB for 
Review and Approval; Public Comment Request

AGENCY: Health Resources and Services Administration, HHS.

ACTION: Notice.

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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 [email protected] 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 [email protected] or call (301) 443-
1984.

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

[[Page 41407]]

hours estimated for this ICR are summarized in the table below.

                                    Total Estimated Annualized Burden--Hours
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                                                                                      Average
                                     Number of       Number of         Total        burden per     Total burden
    Type of application form        respondents    responses per     responses     response  (in       hours
                                                    respondent                        hours)
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Form 1A: General Information               1,700               1           1,700             2.0           3,400
 Worksheet......................
Form 1B: BPHC Funding Request                400               1             400             1.0             400
 Summary........................
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                            650               1             650             1.0             650
 Characteristics................
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/                 1,600               1           1,600             0.5             800
 Locations......................
Form 6A: Current Board Member              1,600               1           1,600             1.0           1,600
 Characteristics................
Form 6B: Request for Waiver of               150               1             150             1.0             150
 Governance Requirements........
Form 8: Health Center Agreements             250               1             250             1.0             250
Form 9: Need for Assistance                  650               1             650             5.0           3,250
 Worksheet......................
Form 10: Annual Emergency                  1,600               1           1,600             1.0           1,600
 Preparedness Report............
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                   700               1             700             2.0           1,400
 Service Delivery Site..........
Checklist for Deleting Existing              700               1             700             2.0           1,400
 Service Delivery Site..........
Checklist for Adding New Service             700               1             700             2.0           1,400
Checklist for Deleting Existing              700               1             700             2.0           1,400
 Service........................
Checklist for Replacing Existing             700               1             700             2.0           1,400
 Service Delivery Site..........
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                    50               1              50             1.0              50
 Target Population..............
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
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    Total.......................          30,850  ..............          30,850  ..............          44,025
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    Dated: July 3, 2013.
Bahar Niakan,
Director, Division of Policy and Information Coordination.
[FR Doc. 2013-16604 Filed 7-9-13; 8:45 am]
BILLING CODE 4165-15-P