Notice2025-22757
Agency Information Collection Activities: Proposed Collection: Public Comment Request; Information Collection Request Title: Health Center Program Forms-OMB No. 0915-0285-Revision
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
December 15, 2025
Issuing agencies
Health and Human Services DepartmentHealth Resources and Services Administration
Abstract
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.
Full Text
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<title>Federal Register, Volume 90 Issue 238 (Monday, December 15, 2025)</title>
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[Federal Register Volume 90, Number 238 (Monday, December 15, 2025)]
[Notices]
[Pages 58019-58021]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2025-22757]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
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.
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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 <a href="/cdn-cgi/l/email-protection#bcccddccd9cecbd3ced7fcd4cecfdd92dbd3ca"><span class="__cf_email__" data-cfemail="730312031601041c0118331b0100125d141c05">[email protected]</span></a> 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 <a href="/cdn-cgi/l/email-protection#2f5f4e5f4a5d58405d446f475d5c4e01484059"><span class="__cf_email__" data-cfemail="493928392c3b3e263b2209213b3a28672e263f">[email protected]</span></a> 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
[[Page 58020]]
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:
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Form No./name Description of modifications
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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 Removed patient board member
Characteristics. 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 Revised checklist statements
Scope. and questions.
Checklist for Deleting a Service from Revised checklist statements
Scope. and questions.
Checklist for Deleting a Service Site Revised checklist statements
from Scope. and questions.
Health Center Controlled Networks Clarified and updated
Progress Report. 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 Minor language updates; no
Act (NHHCIA) Non-Competing content changes.
Continuation (NCC) Clinical
Performance Measures.
NHHCIA NCC Financial Performance Minor language updates; no
Measures. 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) Minor language updates; no
Evaluative Measures Report. 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.
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HRSA will add the following forms necessary for data collection and
change in scope requests to simplify the process:
<bullet> Grant Number form
<bullet> Checklist for Replacing a Service Site in Scope
<bullet> Checklist for Adding a Transitional Care in Carceral Setting
Site to Scope
<bullet> Checklist for Form 5B Scope Adjustment
<bullet> Checklist for Form 5A Scope Adjustment
<bullet> 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:
<bullet> Applicant Qualification Criteria Form
<bullet> Checklist for Adding a New Target Population
<bullet> Environmental Information and Documentation
<bullet> Form 3A: Look-Alike Budget Information
<bullet> Form 4: Community Characteristics
<bullet> Form 5C: Other Activities/Locations
<bullet> Fiscal Year 2020 Ending the HIV Epidemic Primary Care HIV
Prevention PCHP Progress Reporting
<bullet> HRSA EHBs Action Plan
<bullet> Patient Impact Form
<bullet> Patient Target and Calculations
<bullet> Progress Report--Non-Capital Investments
<bullet> Project Overview Form
<bullet> 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.
[[Page 58021]]
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 (hours) hours
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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 466 1 466 2.00 932.00
Scope.......................................
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 5 1 5 1.00 5.00
guarantee)..................................
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 1,370 1 1,370 1.00 1,370.00
Requirements................................
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 29 1 29 1.50 43.50
Progress Report.............................
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 400 1 400 1.00 400.00
Patient Impact).............................
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 54 10 540 1.50 810.00
Populations Progress Report.................
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 250 1 250 1.50 375.00
Scope.......................................
Checklist for Adding a Transitional Care in a 50 1 50 1.00 50.00
Carceral Setting Site to Scope..............
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
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Total.................................... ............ .............. 27,597 ........... 28,903.05
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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.
[FR Doc. 2025-22757 Filed 12-12-25; 8:45 am]
BILLING CODE 4165-15-P
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