[Federal Register Volume 75, Number 112 (Friday, June 11, 2010)]
[Notices]
[Pages 33310-33311]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-14108]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
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
[email protected] or call the HRSA Reports Clearance Office on (301)
443-1129.
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:
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Number of Responses per Total Hours per Total burden
Type of application form respondents respondent responses response hours
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General Information Worksheet.. 1,034 1 1,034 2.0 2,068
Planning Grant: General 250 1 250 2.5 625
Information Worksheet.........
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- 1,034 1 1,034 2.0 2,068
Competing)....................
Business Plan (Competing)...... 800 1 1,034 4.0 4,136
[[Page 33311]]
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 300 1 300 1.0 300
Checklist.....................
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 150 1 150 1.0 150
Governance Requirements.......
Health Center Affiliation 250 1 250 1.0 250
Certification.................
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 400 1 400 2.0 800
Documentation (EID)...........
Capital Improvement/Investment 700 1 700 1.0 700
Proposal Cover Page...........
Assurances..................... 900 1 900 .5 450
Capital Improvement/Investment 700 1 700 1.0 700
Project Cover.................
Capital Improvement/Investment 700 1 700 .5 350
Project Impact................
Equipment List................. 900 1 900 1.0 900
Other Requirements for Sites... 900 1 900 .5 450
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Total...................... 1,138 1 23,976 ............... 40,161
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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 [email protected] 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.
[FR Doc. 2010-14108 Filed 6-10-10; 8:45 am]
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