The Health Center Program Application Forms

OMB 0915-0285

Health Center Program-specific forms provide information essential for application evaluation, funding and designation recommendation and approval, monitoring, and ensuring compliance with Health Center Program legislative and regulatory requirements. The forms are/will be used by existing health centers and other organizations to apply for grant and non-grant opportunities, renew grant or non-grant designation, and change scope of project.

The latest form for The Health Center Program Application Forms expires 2023-03-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 1 Capital Semi-Annual Progress Report Form and Instruction
Form 15 Funding Request Summary Form (SBHC) Form and Instruction
Form 13 Applicant Qualification Criteria Form Form and Instruction
Form 9a Capital Semi Annual Progress Report Form and Instruction
Form 13 FY 2022 Accelerating Cancer Screening Progress Report Form and Instruction
Form 11 QIF Evaluative Measures Report Form and Instruction
Form 12 Project Cover Page Form and Instruction
Form 7a Progress Report Non-Capital Investment Form and Instruction
Form 7a Patient Impact Form Form and Instruction
Form 6a NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update Form and Instruction
Form 4a NHHCIA NCC Financial Performance Measures Form and Instruction
Form 3a NHHCIA NCC Clinical Performance Measures Form and Instruction
Form 2a QIF Project Plan Form Form and Instruction
Form 1a QIF Progress Report Form and Instruction
Form 39 Program Specific Forms Instructions Form and Instruction
Form 38 Patient Target and Calculations Form and Instruction
Form 37 Participating Health Center List Form and Instruction
Form 18 Form 3A: FQHC Look-Alike Budget Information Form and Instruction
Form 13 Form 1A: General Information Worksheet Form and Instruction
Form 8 Diabetes Action Plan - Quarterly Report Template Form and Instruction
Form 34 HRSA Loan Guarantee Program Application Form and Instruction
Form 10a Health Center Controlled Networks (HCCN) Progress Report Table Form and Instruction
Form 31 Health Center Program Progress Report Form and Instruction
Form 40 Project Narrative Update Form and Instruction
Form 46 Summary Page Form and Instruction
Form 11 Federal Object Class Categories Form and Instruction
Form 29 FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Form and Instruction
Form 28 FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting Form and Instruction
Form 32 Health Center Program: Supplemental Information Form and Instruction
Form 44 Project Work Plan Form and Instruction
Form 35 Operational Plan Form and Instruction
Form 43 Project Qualification Criteria Form and Instruction
Form 27 Funding Sources Form and Instruction
Form 10 Expanded Services Form and Instruction
Form 4 Checklist for Adding a New Target Population Form and Instruction
Form 36 Other Requirements for Sites Form and Instruction
Form 9 Equipment List Form and Instruction
Form 41 Project Overview Form and Instruction
Form 45 Proposal Cover Page Form and Instruction
Form 6 Checklist for Deleting Existing Service Delivery Site Form and Instruction
Form 3 Checklist for Adding a new Service Delivery Site Form and Instruction
Form 5 Checklist for Deleting Existing Service Form and Instruction
Form 2 Checklist for Adding New Service Form and Instruction
Form 12 Financial Performance Indicators Form and Instruction
Form 26 Form 12: Organization Contacts Form and Instruction
Form 7 Clinical Performance Measures Form and Instruction
Form 33 HRSA EHBs Action Plan Form and Instruction
Form 42 Project Plan Form and Instruction
Form 25 Form 8: Health Center Agreements Form and Instruction
Form 24 Form 6B: Request for Waiver of Governance Requirements Form and Instruction
Form 23 Form 6A: Current Board Member Characteristics Form and Instruction
Form 22 Form 5C: Other Activities/Locations Form and Instruction
Form 21 Form 5B: Service Sites Form and Instruction
Form 20 Form 5A: Services Provided Form and Instruction
Form 19 Form 4: Community Characteristics Form and Instruction
Form 17E Form 3: Income Analysis Form and Instruction
Form 16 Form 2: Staffing Profile Form and Instruction
Form 15 Form 1C: Documents on File Form and Instruction
Form 14 Form 1B: BPHC Funding Request Summary Form and Instruction
FY23 Supporting Statement Final Edited.docx Supporting Statement A
Capital Semi-Annual Progress Report Form and Instruction
Funding Request Summary Form (SBHC) Form and Instruction
Applicant Qualification Criteria Form Form and Instruction
Capital Semi Annual Progress Report Form and Instruction
FY 2022 Accelerating Cancer Screening Progress Report Form and Instruction
QIF Evaluative Measures Report Form and Instruction
Project Cover Page Form and Instruction
Progress Report Non-Capital Investment Form and Instruction
Patient Impact Form Form and Instruction
NHHCIA NCC Income Analysis/ Plan Progress Report/ Work Plan Update Form and Instruction
NHHCIA NCC Financial Performance Measures Form and Instruction
NHHCIA NCC Clinical Performance Measures Form and Instruction
QIF Project Plan Form Form and Instruction
QIF Progress Report Form and Instruction
Program Specific Forms Instructions Form and Instruction
Patient Target and Calculations Form and Instruction
Participating Health Center List Form and Instruction
Form 3A: FQHC Look-Alike Budget Information Form and Instruction
Form 1A: General Information Worksheet Form and Instruction
Diabetes Action Plan - Quarterly Report Template Form and Instruction
HRSA Loan Guarantee Program Application Form and Instruction
Health Center Controlled Networks (HCCN) Progress Report Table Form and Instruction
Health Center Program Progress Report Form and Instruction
Project Narrative Update Form and Instruction
Summary Page Form and Instruction
Federal Object Class Categories Form and Instruction
FY 2020 Ending the HIV Epidemic - Primary Care HIV Prevention (PHCP) Progress Reporting Form and Instruction
FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting Form and Instruction
Health Center Program: Supplemental Information Form and Instruction
Project Work Plan Form and Instruction
Operational Plan Form and Instruction
Project Qualification Criteria Form and Instruction
Funding Sources Form and Instruction
Expanded Services Form and Instruction
Checklist for Adding a New Target Population Form and Instruction
Other Requirements for Sites Form and Instruction
Equipment List Form and Instruction
Project Overview Form and Instruction
Proposal Cover Page Form and Instruction
Checklist for Deleting Existing Service Delivery Site Form and Instruction
Checklist for Adding a new Service Delivery Site Form and Instruction
Checklist for Deleting Existing Service Form and Instruction
Checklist for Adding New Service Form and Instruction
Financial Performance Indicators Form and Instruction
Form 12: Organization Contacts Form and Instruction
Clinical Performance Measures Form and Instruction
HRSA EHBs Action Plan Form and Instruction
Project Plan Form and Instruction
Form 8: Health Center Agreements Form and Instruction
Form 6B: Request for Waiver of Governance Requirements Form and Instruction
Form 6A: Current Board Member Characteristics Form and Instruction
Form 5C: Other Activities/Locations Form and Instruction
Form 5B: Service Sites Form and Instruction
Form 5A: Services Provided Form and Instruction
Form 4: Community Characteristics Form and Instruction
Form 3: Income Analysis Form and Instruction
Form 2: Staffing Profile Form and Instruction
Form 1C: Documents on File Form and Instruction
Form 1B: BPHC Funding Request Summary Form and Instruction

All Historical Document Collections

202301-0915-005 Approved without change	Revision of a currently approved collection	2023-02-08
202011-0915-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-11-30
202005-0915-003 Approved with change	No material or nonsubstantive change to a currently approved collection	2020-05-26
202001-0915-001 Approved with change	Revision of a currently approved collection	2020-01-09
201608-0915-003 Approved with change	Revision of a currently approved collection	2016-08-16
201410-0915-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-10-09
201312-0915-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2013-12-20
201307-0915-005 Approved with change	Revision of a currently approved collection	2013-07-22
201010-0915-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2010-10-29
201007-0915-001 Approved without change	Revision of a currently approved collection	2010-07-01
200706-0915-005 Approved without change	Extension without change of a currently approved collection	2007-06-20
200402-0915-001 Approved with change	Existing collection in use without an OMB Control Number	2004-02-19

OMB Details

Capital Semi-Annual Progress Report

Federal Enterprise Architecture: Health - Health Care Services

Form 1	Capital Semi Annual Progress Report (SAPR).docx	Fillable Fileable	Form and instruction
Form 2	Progress Report COVID Mark Up_5.26.20.pdf	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.