HRSA Health Center Program Forms OMB Review

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Notice

Agency Information Collection Activities: Submission to OMB for Review and Approval; Public Comment Request; Health Center Program Forms-OMB No. 0915-0285-Revision

A Notice by the Health Resources and Services Administration on 04/22/2026

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3. Document Details Published Content - Document Details Agencies Department of Health and Human Services Health Resources and Services Administration Document Citation 91 FR 21505 Document Number 2026-07793 Document Type Notice Pages 21505-21508 (4 pages) Publication Date 04/22/2026 Published Content - Document Details

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Department of Health and Human Services

Health Resources and Services Administration

AGENCY:

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 ( printed page 21506) 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. HRSA seeks comments from the public regarding the burden estimate below or any other aspect of the ICR. 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 May 22, 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) 443-3983.

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 and adjust fees based on income and family size. Nearly 1,400 health centers operate more than 16,000 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 scope of project.

A 60-day notice published in the Federal Register on December 15, 2025, vol. 90, No. 238; pp. 58019-21. There was one comment. The commenter noted that tracking and managing service areas defined by Form 5B ZIP codes is complex when a health center uses the Health Center Program forms. In response, HRSA is currently exploring improvements to the Health Center Program GeoCare Navigator to help health centers better visualize their service area prior to requesting changes to their service area.

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 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 FTE 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 (previously “Service 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 New Service	Revised checklist statements and questions.
Checklist for Adding a New Service Delivery Site	Revised checklist statements and questions.
Checklist for Deleting Existing Service	Revised checklist statements and questions.
Checklist for Deleting Existing Service Delivery Site	Revised checklist statements and questions.
HCCN Progress Report	Clarified and updated objectives; reduced the total number of objectives.
Impact Form (previously “Expanded Services Patient Impact”)	Streamlined form to request generic information based on the Notice of Funding Opportunity.
Loan Guarantee Program Financial Performance Measures (previously: Financial Performance Indicators)	Three questions removed.
NHHCIA 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.
NH-NCC Project Work Plan Update	Minor language updates; no content changes.
Project Cover Page	Minor language updates; no content changes.
Project Narrative Update	Minor language updates; no content changes.
Project Overview Form	Converted to a generic form usable across funding opportunities; updated questions.
Project Qualification Criteria	Removed 3 questions.
Project Work Plan	Updated to indicate which questions are for PCAs vs NTAPs. Updated 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.
( printed page 21507)
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 Adding a Transitional Care in Carceral Setting Site to Scope
• QIF Transitions in Care for Justice-Involved Populations Progress Report
• QIF Transitions in Care for Justice-Involved Populations Evaluative Measures Report
• LAL Cover page
• Checklist for Form 5A Scope Adjustments

• Checklist for Form 5B Scope Adjustments
  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

• 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 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
respondents | Number of
responses per
respondent | Total
responses | Average
burden per
response
(hours) | Total burden
hours |
| --- | --- | --- | --- | --- | --- |
| Capital Semi-Annual Progress Report | 500 | 2 | 1,000 | 1.00 | 1,000.00 |
| Checklist for Adding a New Service | 450 | 1 | 450 | 2.00 | 900.00 |
| Checklist for Adding a New Service Delivery Site | 1,480 | 1 | 1,480 | 2.00 | 2,960.00 |
| Checklist for Deleting Existing Service | 500 | 1 | 500 | 2.00 | 1,000.00 |
| Checklist for Deleting Existing Service Delivery Site | 750 | 1 | 750 | 2.00 | 1,500.00 |
| 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 (previously: Financial Performance Indicators) | 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 5C: Other Activities/Locations | 550 | 1 | 550 | 0.25 | 137.50 |
| 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 |
| NH-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 |
| ( printed page 21508) |
| 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 TJI Evaluative Measures Report | 54 | 10 | 540 | 1.50 | 810.00 |
| QIF TJI 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 |
| LAL 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 |
| Checklist for Form 5A Scope Adjustments | 1,875 | 1 | 1,875 | 0.50 | 937.50 |
| Checklist for Form 5B Scope Adjustments | 1,695 | 1 | 1,695 | 0.50 | 847.50 |
| Total | 28,588 | | 30,350.00 | | 32,785.55 |
Maria G. Button,

Director, Executive Secretariat.

[FR Doc. 2026-07793 Filed 4-21-26; 8:45 am]

BILLING CODE 4165-15-P

Published Document: 2026-07793 (91 FR 21505)