Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics

Forms and Documents

Document Name	Status
Form 1 Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics Form	Modified
0293 Free Clinic Application Non Substantive Change Memo - CLEAN.docx Justification for No Material/Nonsubstantive Change	2021-05-18
0293 60 Day FRN Comment Chart October 2020.docx Supplementary Document	2020-10-29
0293 Supporting Statement Ocotober 2020 BPHC.docx Supporting Statement A	2020-10-29
0293 Privacy Impact Assessment.pdf Supplementary Document	2017-10-25

IC Document Collections

IC ID	Document Title	Status
6548	Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics Form	Modified

ICR Details

OMB Control No: 0915-0293	ICR Reference No: 202105-0915-001
Status: Received in OIRA	Previous ICR Reference No: 202010-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/18/2021

	Requested	Previously Approved
Expiration Date	01/31/2024	01/31/2024
Responses	1,122	1,122
Time Burden (Hours)	2,244	2,244
Cost Burden (Dollars)	0	0

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Abstract: Deemed status for FTCA medical malpractice coverage requires HRSA approval of an application for deeming of certain eligible individuals from a sponsoring Free Clinic. The FTCA Program Deeming Sponsorship Application for Free Clinics is an electronic application submitted to HRSA through the Electronic Handbooks as part of the process of deeming qualified health care professionals, board members, officers, and individual contractors.

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Authorizing Statute(s): US Code: 42 USC 233(o) Name of Law: Health Insurance Portability and Accountability Act of 1996
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 47803	08/06/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 69628	11/03/2020
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics	1, 1 TC	CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION CLEAN.docx ,   CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION tracked changes.docx

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,122	1,122	0	0	0	0
Annual Time Burden (Hours)	2,244	2,244	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $203,342

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/18/2021

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