Agency Information Collection Activities: Submission to OMB for Review and Approval; Public Comment Request; Health Center Program Forms, OMB No. 0915-0285-Revision, 71433-71435 [2019-27909]
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Federal Register / Vol. 84, No. 248 / Friday, December 27, 2019 / Notices
Court of Federal Claims No: 19–1759V
35. Nicole Abrams-Kelly, Huntersville, North
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40. Olga Capkeviciene, Lakewood, Ohio,
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42. Morgan Gaffney, Washington, District of
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43. Katherine Beltz, Huntersville, North
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46. Noelle Lynn Czopek on behalf of C. L. H.,
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47. Ann M. Arpino, New Haven, Connecticut,
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48. Edwin Weiss, New York, New York,
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51. Randy Li, Fort Polk, Louisiana, Court of
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52. Donna Faye McKenney, Clackamas,
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53. Phillip Woods, Novi, Michigan, Court of
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54. Geoffrey Clive, Kansas City, Missouri,
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55. Connie Suzann Mundinger, Columbia,
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56. Carl Johnson, Eagan, Minnesota, Court of
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57. Marjorie DeCamara, Manheim,
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58. Michelle Celentano, Tucson, Arizona,
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59. Claudia Marquez, Washington, District of
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60. Thomas Bakker, Scottsdale, Arizona,
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61. Leigh-Anne Garry on behalf of M. G.,
Flourtown, Pennsylvania, Court of
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62. Maria Reiser Manwill, West Valley City,
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63. Lori Hoeffken, Richmond, Texas, Court of
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64. Tyler Ramdhanie, Halethorpe, Maryland,
Court of Federal Claims No: 19–1820V
VerDate Sep<11>2014
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65. Misty Gehrke, Vancouver, Washington,
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66. Joyce C. Briggs, Durham, North Carolina,
Court of Federal Claims No: 19–1822V
67. Michael Dean Vucenic, Modesto,
California, Court of Federal Claims No:
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68. Melissa Fischer, Clawson, Michigan,
Court of Federal Claims No: 19–1825V
[FR Doc. 2019–27963 Filed 12–26–19; 8:45 am]
BILLING CODE 4165–15–P
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
Forms, OMB No. 0915–0285—Revision
Health Resources and Services
Administration (HRSA), Department of
Health and Human Services.
ACTION: Notice.
AGENCY:
In compliance with of the
Paperwork Reduction Act of 1995,
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. OMB may act on
HRSA’s ICR only after the 30 day
comment period for this notice has
closed.
SUMMARY:
Comments on this ICR should be
received no later than January 27, 2020.
ADDRESSES: Submit your comments,
including the ICR Title, to the desk
officer for HRSA, either by email to
OIRA_submission@omb.eop.gov 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 Lisa
Wright-Solomon, the HRSA Information
Collection Clearance Officer at
paperwork@hrsa.gov or call (301) 443–
1984.
SUPPLEMENTARY INFORMATION:
Information Collection Request Title:
Health Center Program Forms OMB No.
0915–0285—Revision.
Abstract: The Health Center Program,
administered by HRSA, is authorized
under section 330 of the Public Health
Service (PHS) Act, most recently
amended by section 50901(b) of the
Bipartisan Budget Act of 2018, Public
Law 115–123. Health centers are
DATES:
PO 00000
Frm 00086
Fmt 4703
Sfmt 4703
71433
community-based and patient-directed
organizations that deliver affordable,
accessible, quality, and cost-effective
primary health care services to patients
regardless of their ability to pay. Nearly
1,400 health centers operate
approximately 12,000 service delivery
sites that provide primary health care to
more than 27 million people in every
U.S. state, the District of Columbia,
Puerto Rico, the U.S. Virgin Islands, and
the Pacific Basin. HRSA utilizes forms
for new and existing health centers and
other entities to apply for various grant
and non-grant opportunities, renew
grant and non-grant designations, report
progress, and change their scopes of
project.
A 60-day notice was published in the
Federal Register on April 8, 2019, vol.
84, No. 67; pp. 13937–38. No public
comments were received.
Need and Proposed Use of the
Information: Health Center Programspecific forms are necessary for Health
Center Program award processes and
oversight. These forms provide HRSA
staff and objective review committee
panels with information essential for
application evaluation, funding
recommendation and approval,
designation, and monitoring. These
forms also provide HRSA staff with
information essential for evaluating
compliance with Health Center Program
legislative and regulatory requirements.
HRSA intends to make several
changes to its forms:
• HRSA will modify the following
forms to streamline and clarify data
(e.g., text changes, updated instructions)
currently being collected: 1A, 1B, 1C, 2,
3, 3A, 4, 5A, 5B, 5C, 6A, 8, 12, Checklist
for Adding a New Service, Checklist for
Adding a New Service Delivery Site,
Checklist for Adding a New Target
Population, Checklist for Deleting
Existing Service, Checklist for Deleting
Existing Service Delivery Site, Clinical
Performance Measures, Equipment List,
Expanded Services, Federal Object Class
Categories, Financial Performance
Measures, Funding Sources, Health
Center Controlled Networks (HCCN)
Progress Report Table, Operational Plan,
Program Specific Forms Instructions,
Project Qualification Criteria, Project
Work Plan, Proposal Cover Page, and
the Summary Page.
• HRSA will rename the following
forms: Substance Abuse Progress Report
will be changed to Health Center
Program Progress Report, Program
Narrative Update will be changed to
Project Narrative Update, and Outreach
and Enrollment Supplemental form will
be changed to Health Center Program:
Supplemental Information.
E:\FR\FM\27DEN1.SGM
27DEN1
71434
Federal Register / Vol. 84, No. 248 / Friday, December 27, 2019 / Notices
• HRSA will add the following forms
to collect information to support
funding applications and program
monitoring: Capital Semi-Annual
Progress Report, Diabetes Action Plan
Quarterly Report Template, FY 2018
Expanding Access to Quality Substance
Use Disorder and Mental Health
Services (SUD–MH)/Integrated
Behavioral Health Services (IBHS)
Progress Reporting, FY2020 Ending the
HIV Epidemic—Primary Care HIV
Prevention Progress Reporting, HRSA
Electronic Handbooks Action Plan,
HRSA Loan Guarantee Program
Application, Participating Health Center
List, Patient Target and Calculations,
Project Overview, and Project Plan.
• HRSA will remove the following
forms to further streamline information
collected by HRSA and reduce burden:
Alterations and Renovations Project
Cover Page, Form 9: Need for
Assistance, Form 10: Annual Emergency
Preparedness Report, HCCN Work Plan,
and Zika Progress Report.
Since the submission of the 60-day
Federal Register notice (FRN), there are
5 additional new forms (for a total of 10
new forms) due to new initiatives that
required clearance (2 HIV fundingrelated forms, 2 diabetes funding-related
forms, and 1 HCCN funding-related
form); the data needed for the new
initiatives could not be captured in
forms previously approved. Please note,
the 60-day FRN included one form
identified as ‘‘new’’ (Project Work Plan);
however, that form was actually
included in the previous OMB package
submitted in 2017. The correction has
been made in this 30-day FRN and this
form is no longer listed as new in this
documentation.
The 60-day FRN request contained
42,530 burden hours. However, this
final 30-day notice includes an
additional 16,712 burden hours, for a
new total of 59,242 burden hours.
Likely Respondents: Health Center
Program award recipients (those funded
under section 330 of the PHS Act);
Health Center Program look-alikes; state
and national trade associations; and
other organizations seeking Health
Center Program 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
Number of
respondents
jbell on DSKJLSW7X2PROD with NOTICES
Form name
Capital Semi-Annual Progress Report (new) ......................
Checklist for Adding a New Service ....................................
Checklist for Adding a New Service Delivery Site ..............
Checklist for Adding a New Target Population ...................
Checklist for Deleting Existing Service ................................
Checklist for Deleting Existing Service Delivery Site ..........
Clinical Performance Measures ...........................................
Diabetes Action Plan—Quarterly Report Template (new) ...
Equipment List .....................................................................
Expanded Services ..............................................................
Federal Object Class Categories .........................................
Financial Performance Measures ........................................
Form 1A: General Information Worksheet ...........................
Form 1B: BPHC Funding Request Summary ......................
Form 1C: Documents on File ..............................................
Form 2: Staffing Profile ........................................................
Form 3: Income Analysis .....................................................
Form 3A: FQHC Look-Alike Budget Information .................
Form 4: Community Characteristics ....................................
Form 5A: Services Provided ................................................
Form 5B: Service Sites ........................................................
Form 5C: Other Activities/Locations ....................................
Form 6A: Current Board Member Characteristics ...............
Form 6B: Request for Waiver of Board Member Requirements ................................................................................
Form 8: Health Center Agreements ....................................
Form 12: Organization Contacts ..........................................
Funding Sources ..................................................................
FY2018 Expanding Access to Quality SUD–MH/IBHS
Progress Reporting (new) ................................................
FY2020 Ending the HIV Epidemic—Primary Care HIV Prevention Progress Reporting (new) ...................................
HCCN Progress Report Table .............................................
Health Center Program Progress Report (previously Substance Abuse Progress Report) .......................................
Health Center Program: Supplemental Information (previously Outreach and Enrollment Supplemental Form) ...
HRSA Electronic Handbooks Action Plan (new) .................
HRSA Loan Guarantee Program Application (new) ............
Operational Plan ..................................................................
VerDate Sep<11>2014
18:44 Dec 26, 2019
Jkt 250001
PO 00000
Frm 00087
Number of
responses per
respondent
Total
responses
Average
burden per
response
(in hours)
Total burden
hours
996
450
1,480
100
500
750
1,058
1,058
1,375
996
735
1,058
1,058
1,000
1,058
1,058
1,058
50
1,058
1,058
1,508
1,058
1,058
2
1
1
1
1
1
1
4
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1,992
450
1,480
100
500
750
1,058
4,232
1,375
996
735
1,058
1,058
1,000
1,058
1,058
1,058
50
1,058
1,058
1,508
1,058
1,058
1.00
2.00
2.00
2.00
2.00
2.00
3.50
2.00
1.00
1.00
0.25
1.50
1.00
0.75
0.50
1.00
1.00
1.00
1.00
1.00
1.00
0.50
1.00
1,992
900
2,960
200
1,000
1,500
3,703
8,464
1,375
996
184
1,587
1,058
750
529
1,058
1,058
50
1,058
1,058
1,508
529
1,058
1,058
1,058
1,058
735
1
1
1
1
1,058
1,058
1,058
735
1.00
1.00
0.50
0.50
1,058
1,058
529
368
1,375
3
4,125
1.00
4,125
182
90
1
1
182
90
1.00
1.00
182
90
735
1
735
1.00
735
500
1,058
20
500
1
4
1
1
500
4,232
20
500
1.00
1.00
1.00
3.00
500
4,232
20
1,500
Fmt 4703
Sfmt 4703
E:\FR\FM\27DEN1.SGM
27DEN1
71435
Federal Register / Vol. 84, No. 248 / Friday, December 27, 2019 / Notices
TOTAL ESTIMATED ANNUALIZED BURDEN HOURS—Continued
Number of
respondents
Form name
Total
responses
Average
burden per
response
(in hours)
Total burden
hours
Other Requirements for Sites ..............................................
Participating Health Center List (new) .................................
Patient Target and Calculations (new) ................................
Program Specific Forms Instructions ...................................
Project Narrative Update (previously Program Narrative
Update) .............................................................................
Project Overview (new) ........................................................
Project Plan (new) ...............................................................
Project Qualification Criteria ................................................
Project Work Plan ................................................................
Proposal Cover Page ...........................................................
Summary Page ....................................................................
600
90
1,058
1,500
1
1
1
1
600
90
1,058
1,500
0.50
1.00
1.00
1.00
300
90
1,058
1,500
883
182
182
735
135
735
1,558
1
1
3
1
1
1
1
883
182
546
735
135
735
1,558
4.00
1.00
1.50
1.00
4.00
1.00
0.50
3,532
182
819
735
540
735
779
Total Hours ...................................................................
37,605
........................
48,063
........................
59,242
Maria G. Button,
Director, Executive Secretariat.
Health, National Institutes of Allergy and
Infectious Diseases, 5601 Fishers Lane,
Rockville, MD 20852, 301–761–3100,
mailto:ann-marie.cruz@nih.gov.
(Catalogue of Federal Domestic Assistance
Program Nos. 93.855, Allergy, Immunology,
and Transplantation Research; 93.856,
Microbiology and Infectious Diseases
Research, National Institutes of Health, HHS)
[FR Doc. 2019–27909 Filed 12–26–19; 8:45 am]
BILLING CODE 4165–15–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
National Institutes of Health
National Institute of Allergy and
Infectious Diseases; Notice of Closed
Meeting
Pursuant to section 10(d) of the
Federal Advisory Committee Act, as
amended, notice is hereby given of the
following meeting.
The meeting will be closed to the
public in accordance with the
provisions set forth in sections
552b(c)(4) and 552b(c)(6), Title 5 U.S.C.,
as amended. The contract proposals and
the discussions could disclose
confidential trade secrets or commercial
property such as patentable material,
and personal information concerning
individuals associated with the contract
proposals, the disclosure of which
would constitute a clearly unwarranted
invasion of personal privacy.
jbell on DSKJLSW7X2PROD with NOTICES
Number of
responses per
respondent
Name of Committee: National Institute of
Allergy and Infectious Diseases Special
Emphasis Panel; HHS–NIH–CDC–SBIR PHS
2020–1: Reagents for Immunologic Analysis
of Non-Mammalian and Underrepresented
Mammalian Models (Topic 083).
Date: January 21, 2020.
Time: 1:00 p.m. to 5:00 p.m.
Agenda: To review and evaluate contract
proposals.
Place: National Institutes of Health, 5601
Fishers Lane, Rockville, MD 20892
(Telephone Conference Call).
Contact Person: Ann Marie M. Brighenti,
Ph.D., Scientific Review Officer, Program
Management & Operations Branch, Division
of Extramural Activities, Scientific Review
Program, Room 3E71, National Institutes of
VerDate Sep<11>2014
18:44 Dec 26, 2019
Jkt 250001
Dated: December 19, 2019.
Tyeshia M. Roberson,
Program Analyst, Office of Federal Advisory
Committee Policy.
[FR Doc. 2019–27860 Filed 12–26–19; 8:45 am]
BILLING CODE 4140–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
National Institutes of Health
National Institute of Allergy and
Infectious Diseases; Notice of
Meetings
Pursuant to section 10(a) of the
Federal Advisory Committee Act, as
amended, notice is hereby given of
meetings of the AIDS Research Advisory
Committee, NIAID.
The meetings will be open to the
public, with attendance limited to space
available. Individuals who plan to
attend and need special assistance, such
as sign language interpretation or other
reasonable accommodations, should
notify the Contact Person listed below
in advance of the meeting.
Name of Committee: AIDS Research
Advisory Committee, NIAID.
Date: January 27, 2020.
Time: 1:00 p.m. to 5:00 p.m.
Agenda: Reports from the Division Director
and other staff.
Place: National Institutes of Health,
Natcher Building, Conference Rooms E1/E2,
45 Center Drive, Bethesda, MD 20892.
PO 00000
Frm 00088
Fmt 4703
Sfmt 4703
Contact Person: Martin Gutierrez, Program
Coordinator, Scientific Planning and
Operations, Division of AIDS, Room 8D50,
National Institutes of Health/NIAID, 5601
Fishers Lane, MSC 98231, Rockville, MD
20852–9831, 240–292–4844, mgutierrez@
mail.nih.gov.
Name of Committee: AIDS Research
Advisory Committee, NIAID.
Date: June 1, 2020.
Time: 1:00 p.m. to 5:00 p.m.
Agenda: Reports from the Division Director
and other staff.
Place: National Institutes of Health,
Natcher Building, Conference Rooms E1/E2,
45 Center Drive, Bethesda, MD 20892.
Contact Person: Martin Gutierrez, Program
Coordinator, Scientific Planning and
Operations, Division of AIDS, Room 8D50,
National Institutes of Health/NIAID, 5601
Fishers Lane, MSC 98231, Rockville, MD
20852–9831, 240–292–4844, mgutierrez@
mail.nih.gov.
Name of Committee: AIDS Research
Advisory Committee, NIAID.
Date: September 14, 2020.
Time: 1:00 p.m. to 5:00 p.m.
Agenda: Reports from the Division Director
and other staff.
Place: National Institutes of Health,
Natcher Building, Conference Rooms E1/E2,
45 Center Drive, Bethesda, MD 20892.
Contact Person: Martin Gutierrez, Program
Coordinator, Scientific Planning and
Operations, Division of AIDS, Room 8D50,
National Institutes of Health/NIAID, 5601
Fishers Lane, MSC 98231, Rockville, MD
20852–9831, 240–292–4844, mgutierrez@
mail.nih.gov.
In the interest of security, NIH has
instituted stringent procedures for entrance
onto the NIH campus. All visitor vehicles,
including taxicabs, hotel, and airport shuttles
will be inspected before being allowed on
campus. Visitors will be asked to show one
form of identification (for example, a
government-issued photo ID, driver’s license,
or passport) and to state the purpose of their
visit.
(Catalogue of Federal Domestic Assistance
Program Nos. 93.855, Allergy, Immunology,
and Transplantation Research; 93.856,
E:\FR\FM\27DEN1.SGM
27DEN1
]]>Agencies
[Federal Register Volume 84, Number 248 (Friday, December 27, 2019)]
[Notices]
[Pages 71433-71435]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-27909]
-----------------------------------------------------------------------
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
Forms, OMB No. 0915-0285--Revision
AGENCY: Health Resources and Services Administration (HRSA), Department
of Health and Human Services.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: In compliance with of the Paperwork Reduction Act of 1995,
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. OMB may act on HRSA's ICR only after the 30
day comment period for this notice has closed.
DATES: Comments on this ICR should be received no later than January
27, 2020.
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 Lisa Wright-Solomon, the
HRSA Information Collection Clearance Officer at [email protected] or
call (301) 443-1984.
SUPPLEMENTARY INFORMATION:
Information Collection Request Title: Health Center Program Forms
OMB No. 0915-0285--Revision.
Abstract: The Health Center Program, administered by HRSA, is
authorized under section 330 of the Public Health Service (PHS) Act,
most recently amended by section 50901(b) of the Bipartisan Budget Act
of 2018, Public Law 115-123. Health centers are community-based and
patient-directed organizations that deliver affordable, accessible,
quality, and cost-effective primary health care services to patients
regardless of their ability to pay. Nearly 1,400 health centers operate
approximately 12,000 service delivery sites that provide primary health
care to more than 27 million people in every U.S. state, the District
of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Pacific
Basin. HRSA utilizes forms for new and existing health centers and
other entities to apply for various grant and non-grant opportunities,
renew grant and non-grant designations, report progress, and change
their scopes of project.
A 60-day notice was published in the Federal Register on April 8,
2019, vol. 84, No. 67; pp. 13937-38. No public comments were received.
Need and Proposed Use of the Information: Health Center Program-
specific forms are necessary for Health Center Program award processes
and oversight. These forms provide HRSA staff and objective review
committee panels with information essential for application evaluation,
funding recommendation and approval, designation, and monitoring. These
forms also provide HRSA staff with information essential for evaluating
compliance with Health Center Program legislative and regulatory
requirements.
HRSA intends to make several changes to its forms:
HRSA will modify the following forms to streamline and
clarify data (e.g., text changes, updated instructions) currently being
collected: 1A, 1B, 1C, 2, 3, 3A, 4, 5A, 5B, 5C, 6A, 8, 12, Checklist
for Adding a New Service, Checklist for Adding a New Service Delivery
Site, Checklist for Adding a New Target Population, Checklist for
Deleting Existing Service, Checklist for Deleting Existing Service
Delivery Site, Clinical Performance Measures, Equipment List, Expanded
Services, Federal Object Class Categories, Financial Performance
Measures, Funding Sources, Health Center Controlled Networks (HCCN)
Progress Report Table, Operational Plan, Program Specific Forms
Instructions, Project Qualification Criteria, Project Work Plan,
Proposal Cover Page, and the Summary Page.
HRSA will rename the following forms: Substance Abuse
Progress Report will be changed to Health Center Program Progress
Report, Program Narrative Update will be changed to Project Narrative
Update, and Outreach and Enrollment Supplemental form will be changed
to Health Center Program: Supplemental Information.
[[Page 71434]]
HRSA will add the following forms to collect information
to support funding applications and program monitoring: Capital Semi-
Annual Progress Report, Diabetes Action Plan Quarterly Report Template,
FY 2018 Expanding Access to Quality Substance Use Disorder and Mental
Health Services (SUD-MH)/Integrated Behavioral Health Services (IBHS)
Progress Reporting, FY2020 Ending the HIV Epidemic--Primary Care HIV
Prevention Progress Reporting, HRSA Electronic Handbooks Action Plan,
HRSA Loan Guarantee Program Application, Participating Health Center
List, Patient Target and Calculations, Project Overview, and Project
Plan.
HRSA will remove the following forms to further streamline
information collected by HRSA and reduce burden: Alterations and
Renovations Project Cover Page, Form 9: Need for Assistance, Form 10:
Annual Emergency Preparedness Report, HCCN Work Plan, and Zika Progress
Report.
Since the submission of the 60-day Federal Register notice (FRN),
there are 5 additional new forms (for a total of 10 new forms) due to
new initiatives that required clearance (2 HIV funding-related forms, 2
diabetes funding-related forms, and 1 HCCN funding-related form); the
data needed for the new initiatives could not be captured in forms
previously approved. Please note, the 60-day FRN included one form
identified as ``new'' (Project Work Plan); however, that form was
actually included in the previous OMB package submitted in 2017. The
correction has been made in this 30-day FRN and this form is no longer
listed as new in this documentation.
The 60-day FRN request contained 42,530 burden hours. However, this
final 30-day notice includes an additional 16,712 burden hours, for a
new total of 59,242 burden hours.
Likely Respondents: Health Center Program award recipients (those
funded under section 330 of the PHS Act); Health Center Program look-
alikes; state and national trade associations; and other organizations
seeking Health Center Program 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
----------------------------------------------------------------------------------------------------------------
Number of Average burden
Form name Number of responses per Total per response Total burden
respondents respondent responses (in hours) hours
----------------------------------------------------------------------------------------------------------------
Capital Semi-Annual Progress 996 2 1,992 1.00 1,992
Report (new)...................
Checklist for Adding a New 450 1 450 2.00 900
Service........................
Checklist for Adding a New 1,480 1 1,480 2.00 2,960
Service Delivery Site..........
Checklist for Adding a New 100 1 100 2.00 200
Target Population..............
Checklist for Deleting Existing 500 1 500 2.00 1,000
Service........................
Checklist for Deleting Existing 750 1 750 2.00 1,500
Service Delivery Site..........
Clinical Performance Measures... 1,058 1 1,058 3.50 3,703
Diabetes Action Plan--Quarterly 1,058 4 4,232 2.00 8,464
Report Template (new)..........
Equipment List.................. 1,375 1 1,375 1.00 1,375
Expanded Services............... 996 1 996 1.00 996
Federal Object Class Categories. 735 1 735 0.25 184
Financial Performance Measures.. 1,058 1 1,058 1.50 1,587
Form 1A: General Information 1,058 1 1,058 1.00 1,058
Worksheet......................
Form 1B: BPHC Funding Request 1,000 1 1,000 0.75 750
Summary........................
Form 1C: Documents on File...... 1,058 1 1,058 0.50 529
Form 2: Staffing Profile........ 1,058 1 1,058 1.00 1,058
Form 3: Income Analysis......... 1,058 1 1,058 1.00 1,058
Form 3A: FQHC Look-Alike Budget 50 1 50 1.00 50
Information....................
Form 4: Community 1,058 1 1,058 1.00 1,058
Characteristics................
Form 5A: Services Provided...... 1,058 1 1,058 1.00 1,058
Form 5B: Service Sites.......... 1,508 1 1,508 1.00 1,508
Form 5C: Other Activities/ 1,058 1 1,058 0.50 529
Locations......................
Form 6A: Current Board Member 1,058 1 1,058 1.00 1,058
Characteristics................
Form 6B: Request for Waiver of 1,058 1 1,058 1.00 1,058
Board Member Requirements......
Form 8: Health Center Agreements 1,058 1 1,058 1.00 1,058
Form 12: Organization Contacts.. 1,058 1 1,058 0.50 529
Funding Sources................. 735 1 735 0.50 368
FY2018 Expanding Access to 1,375 3 4,125 1.00 4,125
Quality SUD-MH/IBHS Progress
Reporting (new)................
FY2020 Ending the HIV Epidemic-- 182 1 182 1.00 182
Primary Care HIV Prevention
Progress Reporting (new).......
HCCN Progress Report Table...... 90 1 90 1.00 90
Health Center Program Progress 735 1 735 1.00 735
Report (previously Substance
Abuse Progress Report).........
Health Center Program: 500 1 500 1.00 500
Supplemental Information
(previously Outreach and
Enrollment Supplemental Form)..
HRSA Electronic Handbooks Action 1,058 4 4,232 1.00 4,232
Plan (new).....................
HRSA Loan Guarantee Program 20 1 20 1.00 20
Application (new)..............
Operational Plan................ 500 1 500 3.00 1,500
[[Page 71435]]
Other Requirements for Sites.... 600 1 600 0.50 300
Participating Health Center List 90 1 90 1.00 90
(new)..........................
Patient Target and Calculations 1,058 1 1,058 1.00 1,058
(new)..........................
Program Specific Forms 1,500 1 1,500 1.00 1,500
Instructions...................
Project Narrative Update 883 1 883 4.00 3,532
(previously Program Narrative
Update)........................
Project Overview (new).......... 182 1 182 1.00 182
Project Plan (new).............. 182 3 546 1.50 819
Project Qualification Criteria.. 735 1 735 1.00 735
Project Work Plan............... 135 1 135 4.00 540
Proposal Cover Page............. 735 1 735 1.00 735
Summary Page.................... 1,558 1 1,558 0.50 779
-------------------------------------------------------------------------------
Total Hours................. 37,605 .............. 48,063 .............. 59,242
----------------------------------------------------------------------------------------------------------------
Maria G. Button,
Director, Executive Secretariat.
[FR Doc. 2019-27909 Filed 12-26-19; 8:45 am]
BILLING CODE 4165-15-P
