Agency Information Collection Activities: Submission to OMB for Review and Approval; Public Comment Request; Health Center Program Forms-OMB No. 0915-0285-Revision
In compliance with the Paperwork Reduction Act of 1995, HRSA submitted an Information Collection Request (ICR) to the Office of Management and Budget (OMB) for review and approv...
Health Resources and Services Administration (HRSA), Department of Health and Human Services.
ACTION:
Notice.
SUMMARY:
In compliance with the Paperwork Reduction Act of 1995, HRSA 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 November 19, 2026.
ADDRESSES:
Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to:
www.reginfo.gov/public/do/PRAMain.
Find this particular information collection by selecting “Currently under Review—Open for Public Comments” or by using the search function.
FOR FURTHER INFORMATION CONTACT:
To request a copy of the clearance requests submitted to OMB for review, email Samantha Miller, the HRSA Information Collection Clearance Officer, at
paperwork@hrsa.gov
or call (301) 443-9094.
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 and adjust fees based on income and family size. More than 1,400 health centers operate nearly 17,000 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 scopes of project.
A 60-day notice published in the
Federal Register
on July 30, 2026, Vol. 91, No.145, pp. 48170-72. There were no public comments.
Need and Proposed Use of the Information:
The information HRSA collects from health centers via the Health Center Program-specific forms is necessary for the agency's oversight of Health Center Program awards. HRSA uses the information for program monitoring and for evaluating award recipients' compliance with Health Center Program statutory and regulatory requirements. These forms were approved by OMB on May 31, 2026, following 60- and 30-day public comment periods. Eight forms that were previously approved are being updated and three forms are being added to facilitate monitoring, improve scope of project documentation and oversight, increase the efficiency of the change in scope process, and enhance the accuracy of change in scope requests.
( printed page 66338)
HRSA will modify the following forms to update and clarify data currently being collected:
Forms proposed to be modified: No./name
Description of modifications
Form 5A: Services Provided
Update labels and categories of services.
Form 5B: Sites
Modify fields collecting site information.
Checklist for Form 5A Scope Adjustments
Revise checklist statements and questions.
Checklist for Form 5B Scope Adjustments
Revise checklist statements and questions.
Checklist for Deleting a Service Site from Scope
Previously: Checklist for Deleting Existing Service Delivery Site
Revise checklist statements and questions.
Checklist for Adding a Service Site to Scope
Previously: Checklist for Adding a New Service Delivery Site
Revise checklist statements and questions.
Checklist for Adding a Service to Scope
Previously Checklist for adding a new service
Revise checklist statements and questions.
Checklist for Deleting a Service from Scope
Previously: Checklist for deleting existing service
Revise checklist statements and questions.
HRSA will add the following forms necessary for data collection and change in scope requests to simplify the process:
Checklist for Replacing a Service Site in Scope: Checklist for updating a health center's scope to replace a service site.
Quality Improvement Fund (QIF) Final Report: Collects data on the award recipient's QIF project progress as directed by the notice of funding opportunity.
Loan Guarantee Progress Report: Used to monitor the status of the loan after the guarantee is issued to ensure the health center is compliant in meeting the terms and payment of the loan in the post monitoring phase of the program.
Likely Respondents:
Health Center Program award recipients (those funded under section 330 of the Public Health Service Act) and Health Center Program look-alikes.
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.
These updates will reduce the estimated annual burden by 1,621 hours based on the underlying unrounded burden calculations for the currently approved collection. The reduction reflects modifications to existing forms and the correction of the burden table to exclude
Form 5C: Other Activities/Locations.
Form 5C was removed from the package during revisions completed earlier in 2026 and was inadvertently retained in the published 60-day
Federal Register
notice burden table. Compared with the 60-day notice, excluding Form 5C reduces the totals by 550 respondents, 550 responses, and 137.50 burden hours. In the burden table below, new forms are indicated through bold text, and revised forms are indicated through italicized text. Except for the correction regarding Form 5C described above, all other forms are unchanged.
Total Estimated Annualized Burden Hours
Form title
Number of
respondents
Number of
responses
per
respondent
Total
responses
Average
burden per
response
(hours)
Total
burden
hours
Form 5A: Services Provided
1,400
1
1400
0.25
350.00
Form 5B: Sites
1,400
1
1400
0.25
350.00
Checklist for Form 5A Scope Adjustments
1,000
1
1000
1.00
1,000.00
Checklist for Form 5B Scope Adjustments
2,000
1
2000
1.00
2,000.00
Checklist for Deleting a Service Site from Scope Previously: Checklist for Deleting Existing Service Delivery Site
500
1
500
1.00
500.00
Checklist for Adding a Service Site to Scope Previously: Checklist for Adding a New Service Delivery Site
1,250
1
1250
1.50
1,875.00
Checklist for Adding a Service to Scope Previously: Checklist for adding a new service
450
1
450
1.00
450.00
Checklist for Deleting a Service from Scope Previously: Checklist for deleting existing service
500
1
500
1.00
500.00
Checklist for Replacing a Service Site in Scope
250
1
250
0.75
187.50
QIF Final Report
25
1
25
3.00
75.00
Loan Guarantee Progress Report
22
4
88
1.00
88.00
Capital Semi-Annual Progress Report
500
2
1,000
1.00
1,000.00
Equipment List
130
1
130
0.50
65.00
Federal Object Class Categories Form
500
1
500
0.25
125.00
Loan Guarantee Program Financial Performance Indicators
5
1
5
1.00
5.00
( printed page 66339)
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 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
Health Center Controlled Network 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
400
1
400
1.00
400.00
Native Hawaiian Health Care Improvement Act (NHHCIA) Non-Competing Continuation (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
Native Hawaiian-NCC Project Work Plan Update
5
1
5
1.00
5.00
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 Overview Form
500
1
500
1.00
500.00
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
25
2
50
1.50
75.00
QIF Progress Report
25
12
300
1.50
450.00
QIF Transitions in Care for Justice-Involved Populations Evaluative Measures Report
54
10
540
1.50
810.00
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
Look-Alike Cover page
110
1
110
0.50
55.00
Checklist for Adding a Transitional Care in a Carceral Setting Site to Scope
50
1
50
1.00
50.00
Totals
27,219.00
29,057.00
31,164.55
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.
Use this for formal legal and research references to the published document.
91 FR 66337
Web Citation
Suggested Web Citation
Use this when citing the archival web version of the document.
“Agency Information Collection Activities: Submission to OMB for Review and Approval; Public Comment Request; Health Center Program Forms-OMB No. 0915-0285-Revision,” thefederalregister.org (October 20, 2026), https://thefederalregister.org/documents/2026-21385/agency-information-collection-activities-submission-to-omb-for-review-and-approval-public-comment-request-health-center-.