[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] ----------------------------------------------------------------------- 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. ----------------------------------------------------------------------- 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 ---------------------------------------------------------------------------------------------------------------- Average Number of Number of Total burden per Total burden Type of application form respondents responses per responses response (in hours respondent hours) ---------------------------------------------------------------------------------------------------------------- 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 ------------------------------------------------------------------------------- Total....................... 30,850 .............. 30,850 .............. 44,025 ---------------------------------------------------------------------------------------------------------------- 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