[Federal Register Volume 81, Number 156 (Friday, August 12, 2016)]
[Notices]
[Pages 53489-53491]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-19301]


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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; Health Center Program 
Application Forms

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 no later than September 
12, 2016.

ADDRESSES: Submit your comments, including the ICR 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 (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

[[Page 53490]]

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
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                                                                                            Average
                                                Number of       Number of       Total      burden per    Total
                 Form name                     respondents    responses per   responses     response     burden
                                                               respondent                  (in hours)    hours
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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                         1,000               1        1,000          0.5        500
 Characteristics...........................
Form 6B: Request for Waiver of Governance               100               1          100          1.0        100
 Requirements..............................
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             700               1          700          1.5      1,050
 Site......................................
Checklist for Deleting Existing Service                 700               1          700          1.0        700
 Delivery Site.............................

[[Page 53491]]

 
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                        50               1           50          0.5         25
 Population................................
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               93               1           93           25      2,325
 Report (NEW)..............................
Health Center Controlled Networks Work Plan              93               1           93          5.0        465
 (NEW).....................................
Zika Progress Report (NEW).................              20               4           80          1.0         80
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    Total..................................          34,606  ..............       35,566  ...........     44,608
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Jason E. Bennett,
Director, Division of the Executive Secretariat.
[FR Doc. 2016-19301 Filed 8-11-16; 8:45 am]
 BILLING CODE 4165-15-P