Expanded Services

The Health Center Program Application Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0285 can be found here:

Documents and Forms

Document Name Document Type
Form 10 Expanded Services Form and Instruction
10 Expanded Services Clean.docx Expanded Services Clean.docx Form and Instruction
10E Expanded Services - edits.docx Expanded Services - edits.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Expanded Services	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10	Expanded Services Clean.docx	Expanded Services Clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	10E	Expanded Services - edits.docx	Expanded Services - edits.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 996	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	996	996
Annual IC Time Burden (Hours)	996	996
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.