# Agency Information Collection Activities: Proposed Collection: Public Comment Request; Information Collection Request Title: 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 the requirement for opportunity for public comment on proposed data collection projects of the Paperwork Reduction Act of 1995, HRSA announces plans to submit an Information Collection Request (ICR), described below, to the Office of Management and Budget (OMB). Prior to submitting the ICR to OMB, HRSA seeks comments from the public regarding the burden estimate, below, or any other aspect of the ICR.
**DATES:**
Comments on this ICR should be received no later than February 13, 2026.
**ADDRESSES:**
Submit your comments to *[email protected]* or mail the HRSA Information Collection Clearance Officer, Room 13N82, 5600 Fishers Lane, Rockville, Maryland 20857.
**FOR FURTHER INFORMATION CONTACT:**
To request more information on the proposed project or to obtain a copy of the data collection plans and draft instruments, email *[email protected]* or call Samantha Miller, the HRSA Information Collection Clearance Officer, at (301) 443-3983.
**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 Act (42 U.S.C. 254b). Health centers are 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 more than 16,200 service delivery sites that provide primary health care to more than 32 million people in every U.S. state, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Pacific Basin. HRSA uses 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 scope of project.
*Need and Proposed Use of the Information:* Health Center Program-specific forms are necessary for award processes and oversight of the Health Center Program and other relevant programs. These forms provide HRSA staff and merit review panels with the 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 statutory and regulatory requirements. The current forms will expire April 30, 2026, and this input will be used to inform edits and updates to the Health Center Program's information collection and reporting. HRSA intends to make several changes to its forms.
HRSA will modify the following forms to update and clarify data currently being collected:
| Form No./name | Description of modifications |
| --- | --- |
| Form 1A: General Information Worksheet | Updated response options and text; aligned classification to the current process; removed the visit-count field. |
| Form 2: Staffing Profile | Moved to full time equivalent counts; standardized staffing categories. |
| Form 3: Income Analysis | Question updates with targeted adds/removals. |
| Form 5A: Services Provided | Updated labels and categories of services. |
| Form 5B: Sites | Modified fields collecting site information. |
| Form 6A: Current Board Member Characteristics | Removed patient board member characteristics section. |
| Form 12: Organization Contacts | Consolidated contact information; kept two key contacts. |
| Checklist for Adding a Service to Scope | Revised checklist statements and questions. |
| Checklist for Adding a Service Site to Scope | Revised checklist statements and questions. |
| Checklist for Deleting a Service from Scope | Revised checklist statements and questions. |
| Checklist for Deleting a Service Site from Scope | Revised checklist statements and questions. |
| Health Center Controlled Networks Progress Report | Clarified and updated objectives; reduced the total number of objectives. |
| Impact Form | Streamlined form to request generic information based on the Notice of Funding Opportunity. |
| Native Hawaiian Health Care Improvement Act (NHHCIA) Non-Competing Continuation (NCC) Clinical Performance Measures | Minor language updates; no content changes. |
| NHHCIA NCC Financial Performance Measures | Minor language updates; no content changes. |
| NHHCIA NCC Income Analysis Form | Question updates with targeted adds/removals. |
| Project Cover Page | Minor language updates; no content changes. |
| Project Narrative Update | Minor language updates; no content changes. |
| Project Qualification Criteria | Removed 3 questions. |
| Project Work Plan | Updated to indicate which questions are for Primary Care Associations versus new technology add-on payments; minor language updates. |
| Quality Improvement Fund (QIF) Evaluative Measures Report | Minor language updates; no content changes. |
| QIF Progress Report | Minor language updates; no content changes. |
| QIF Project Plan Form | Converted to a generic form usable across funding opportunities; updated questions. |
| Summary Page (Service Area Competition) | Aligned special medically underserved population terminology with statute; minor language updates. |
| Summary Page (New Access Point) | Aligned special medically underserved population terminology with statute; minor language updates. |
HRSA will add the following forms necessary for data collection and change in scope requests to simplify the process:
• Grant Number form
• Checklist for Replacing a Service Site in Scope
• Checklist for Adding a Transitional Care in Carceral Setting Site to Scope
• Checklist for Form 5B Scope Adjustment
• Checklist for Form 5A Scope Adjustment
• QIF Transitions in Care for Justice-Involved Populations Progress Report
HRSA will remove the following forms to further streamline information collected by HRSA and reduce burden:
• Applicant Qualification Criteria Form
• Checklist for Adding a New Target Population
• Environmental Information and Documentation
• Form 3A: Look-Alike Budget Information
• Form 4: Community Characteristics
• Form 5C: Other Activities/Locations
• Fiscal Year 2020 Ending the HIV Epidemic Primary Care HIV Prevention PCHP Progress Reporting
• HRSA EHBs Action Plan
• Patient Impact Form
• Patient Target and Calculations
• Progress Report—Non-Capital Investments
• Project Overview Form
• Project Plan
*Likely Respondents:* Health Center Program award recipients (those funded under section 330 of the Public Health Service Act) and Health Center Program 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.
| Form name | Number of | Number of | Total | Average | Total |
| --- | --- | --- | --- | --- | --- |
| Capital Semi-Annual Progress Report | 500 | 2 | 1,000 | 1.00 | 1,000.00 |
| Checklist for Adding a Service to Scope | 386 | 1 | 386 | 2.00 | 772.00 |
| Checklist for Adding a Service Site to Scope | 551 | 1 | 551 | 2.00 | 1,102.00 |
| Checklist for Deleting a Service from Scope | 421 | 1 | 421 | 2.00 | 842.00 |
| Checklist for Deleting a Service Site from Scope | 466 | 1 | 466 | 2.00 | 932.00 |
| Equipment List | 130 | 1 | 130 | 0.50 | 65.00 |
| Federal Object Class Categories Form | 500 | 1 | 500 | 0.25 | 125.00 |
| Financial Performance Indicators (loan guarantee) | 5 | 1 | 5 | 1.00 | 5.00 |
| Form 1A: General Information Worksheet | 1,370 | 1 | 1,370 | 0.75 | 1,027.50 |
| Form 1B: Funding Request Summary | 900 | 1 | 900 | 0.75 | 675.00 |
| Form 1C: Documents on File | 1,460 | 1 | 1,460 | 0.50 | 730.00 |
| Form 2: Staffing Profile | 1,370 | 1 | 1,370 | 1.00 | 1,370.00 |
| Form 3: Income Analysis | 1,370 | 1 | 1,370 | 1.00 | 1,370.00 |
| Form 5A: Services Provided | 1,428 | 1 | 1,428 | 0.25 | 357.00 |
| Form 5B: Sites (previously “service sites”) | 1,428 | 1 | 1,428 | 0.25 | 357.00 |
| Form 6A: Current Board Member Characteristics | 1,370 | 1 | 1,370 | 1.00 | 1,370.00 |
| Form 6B: Request for Waiver of Board Member Requirements | 1,370 | 1 | 1,370 | 1.00 | 1,370.00 |
| Form 8: Health Center Agreements | 1,370 | 1 | 1,370 | 1.00 | 1,370.00 |
| Form 12: Organization Contacts | 970 | 1 | 970 | 0.50 | 485.00 |
| Funding Sources | 130 | 1 | 130 | 0.50 | 65.00 |
| FY 2022 Accelerating Cancer Screening Progress Report | 29 | 1 | 29 | 1.50 | 43.50 |
| Grant Number form | 400 | 1 | 400 | 0.25 | 100.00 |
| HCCN Progress Report | 50 | 1 | 50 | 0.50 | 25.00 |
| Health Center Program Progress Report | 130 | 1 | 130 | 1.00 | 130.00 |
| HRSA Loan Guarantee Program Application | 5 | 1 | 5 | 1.00 | 5.00 |
| Impact Form (old name: Expanded Services Patient Impact) | 400 | 1 | 400 | 1.00 | 400.00 |
| NHHCIA NCC Clinical Performance Measures | 5 | 1 | 5 | 1.50 | 7.50 |
| NHHCIA NCC Financial Performance Measures | 5 | 1 | 5 | 0.50 | 2.50 |
| NHHCIA NCC Income Analysis Form | 5 | 1 | 5 | 0.15 | 0.75 |
| NHHCIA Sample Project Work Plan | 2 | 1 | 2 | 0.15 | 0.30 |
| Operational Plan | 350 | 1 | 350 | 2.00 | 700.00 |
| Other Requirements for Sites | 130 | 1 | 130 | 0.50 | 65.00 |
| Participating Health Centers List | 90 | 1 | 90 | 1.00 | 90.00 |
| Project Cover Page | 130 | 1 | 130 | 1.00 | 130.00 |
| Project Narrative Update | 1,325 | 1 | 1,325 | 4.00 | 5,300.00 |
| Project Qualification Criteria | 130 | 1 | 130 | 0.50 | 65.00 |
| Project Work Plan | 508 | 1 | 508 | 4.00 | 2,032.00 |
| Proposal Cover Page | 130 | 1 | 130 | 1.00 | 130.00 |
| QIF Evaluative Measures Report | 54 | 2 | 108 | 1.50 | 162.00 |
| QIF Progress Report | 25 | 12 | 300 | 1.50 | 450.00 |
| QIF Transitions in Care for Justice-Involved Populations Progress Report | 54 | 10 | 540 | 1.50 | 810.00 |
| QIF Project Plan Form | 100 | 1 | 100 | 1.00 | 100.00 |
| Summary Page (New Access Point) | 500 | 1 | 500 | 1.00 | 500.00 |
| Summary Page (Service Area Competition) | 360 | 1 | 360 | 0.50 | 180.00 |
| Checklist for Replacing a Service Site in Scope | 250 | 1 | 250 | 1.50 | 375.00 |
| Checklist for Adding a Transitional Care in a Carceral Setting Site to Scope | 50 | 1 | 50 | 1.00 | 50.00 |
| Checklist for Form 5B Scope Adjustment | 1,695 | 1 | 1,695 | 0.50 | 847.50 |
| Checklist for Form 5A Scope Adjustment | 1,875 | 1 | 1,875 | 0.50 | 937.50 |
| Total | | | 27,597 | | 28,903.05 |
*HRSA specifically requests comments on:* (1) the necessity and utility of the proposed information collection for the proper performance of the agency's functions, (2) the accuracy of the estimated burden, (3) ways to enhance the quality, utility, and clarity of the information to be collected, and (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden.
Maria G. Button,
Director, Executive Secretariat.