Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
2016 National Ryan White Conference on HIV Care and Treatment Conference Evaluation New 2069 1490 0 Form and Instruction 1 Overall 2016 RW Conference Meeting Evaluation
Other-Example
BPHC Customer Service Survey Helpline & Answers New 2315 19 0 Form 1 Survey Instrument Helpline
Form 2 Survey Instrument Answers
Bullying Prevention Training Modules Feedback Forms New 500 100 0 Form and Instruction 1 Form A Bullying Prevention Online Program - 06232015.docx
Form and Instruction 2 Form B Follow-Up Form For Participants in the Bullying Prevention Training Module
Customer Satisfaction Surveys for the Health Literacy Training Program New 2600 225 0 Form 1 Health Literacy Training for Health Professionals Customer Satisfaction Survey
Form 2 Health Literacy Training of Trainers Customer Satisfaction Survey
DATA CoIIN New 340 27 0 Form 1 DATA CoIIN_Platform Training Survey_042018.pdf
DPDB Usability Surveys New 300 300 0 Form 1 NPDB System Form
Form 2 NPDB Website Form
Instruction
Data and Technical Assistance (DATA) Task Order to Support the Infant Mortality CoIIN New 2670 214 0 Form 1 DATA CoIIN_ Post-TA Webinar Evaluation Survey.pdf
Form 2 DATA CoIIN_Post-Stakeholder Webinar Evaluation Survey.pdf
Form 3 DATA CoIIN_Web-based Shared workspace/Online Platform Survey.pdf
Discussion on Teen Organ Donors New 124 71 0 Form and Instruction 1 Attachment 1 Focus Group Informed Consent
Form and Instruction 2 Attachment 2 Focus Group Participant Screener
Form and Instruction 3 Attachment 4 Survey Screener and Questionnaire
Discussions on 50+ Donors New 124 71 0 Form and Instruction 2 20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx
Form and Instruction 3 20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx
Form and Instruction 5 20170303 Attachment 5__FocusGroup_ParticipantScreener (EP_DoT) CLEAN.docx
Form and Instruction 6 20170303 Attachment 6__Survey _Screener Questionnaire - Rd 2 CLEAN Rd 2.docx
HRSA Division of Transplanation (DoT Research on Customer Information Needs Related to Vascularized Composite Allographs Transplants New 724 174 0 Form and Instruction 1 Focus Groups on VCA Donation
Form and Instruction 2 Survey on VCA Donation
HRSA Electronic Handbooks Customer Service Survey New 4825 38 0 Form 1 HRSA EHBs Survey Screenshot
HRSA Office of Acquisition Management and Policy (OAMP) Customer Satisfaction Survey New 864 18 0 Form 1 Example Survey in Survey Monkey.pdf
HRSA Office of Regional Operations (ORO) Outreach & Education Generic Survey Tool New 3000 501 0 Form 1 ORO Generic Evaluation Survey January 2017 - FINAL DRAFT.docx
HRSA Survey Assessment of Objective Peer Review New 2158 540 0 Form 1 Reviewer Survey
Form 2 Chair Survey
HRSA, ACF, and HHS OWH Pilot on Intimate Partner Violence (IPV) Screening and Counseling in Health Centers and Domestic Violence Partner Organizations New 2124 531 0 Form and Instruction 1 Training Survey for Health Organizations
Form and Instruction 2 Follow Up Training Survey for Health Organizations
Form and Instruction 3 Advocate - Provider 6 Month Follow Up Survey for Health Organizations
Form and Instruction 4 Collaborative Behavior Survey
Form and Instruction 5 Health Care Response to Domestic Violence Quality Assessment Program Improvement Tool
Form and Instruction 6a HRSA Patient Feedback Survey - English.docx
Form and Instruction 6b HRSA Patient Feedback Survey - Spanish
Form and Instruction 7a Client Feedback Survey - English
Form and Instruction 7b Client Feedback Survey - Spanish
MCH Connects Survey New 53 5 0 Form and Instruction 1 MCH Connects 3 Month Survey- FINAL.docx
MCH Leadership Competencies New 150 45 0 Form and Instruction 1 Grantee Survey
Maternal and Child Health Epidemiology Training Course - One Year Follow-Up Survey New 40 10 0 Form 1 One-Year Trainee Survey form
Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys New 753 322 0 Form and Instruction A Attachment A -Webinar Customer Satisfaction Survey
Form and Instruction B Attachment B - Targeted TA CoP Customer Satisfaction Survey
Form and Instruction C Attachment C - Newsletter Issue Brief Groupsite Customer Satisfaction Survey
Form and Instruction D Attachment D - Annual Satisfaction Survey
Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Feedback and Satisfaction Surveys New 1650 508 0 Form and Instruction B Attachement B - Town Hall Satisfaction Survey
Form and Instruction C Attachment C - All Grantee Meeting Assessment Form Individual Session
Form and Instruction D Attachment D - All Grantee Meeting Assessment Form Overall
Form and Instruction E Attachment E - Site Visit Assessment Form
NHSC Virtual Job Fair Customer Feedback New 96 16 0 Form and Instruction 1 NHSC Virtual Job Fair SITES Feedback Questions.docx
Form and Instruction 2 NHSC Virtual Job Fair PARTICIPANTS Feedback Questions.docx
Form and Instruction 3 NHSC Virtual Job Fair SITES Follow Up Feedback Questions.docx
Form and Instruction 4 NHSC Virtual Job Fair PARTICIPANTS Follow Up Feedback Questions.docx
ORO Dallas State Strategic Partnership Forum New 70 12 0 Form and Instruction 1 Regional and State Strategic Partnership Forum Form
ORO-Dallas Virtual Participant Satisfaction Survey New 275 3 0 Form and Instruction 1 ORO Dallas Virtual Participant Satisfaction Survey
Office of Regional Operations (ORO) 2016 Tele-Behavioral Health Webcase Series New 90 15 0 Form 1 Telebehavioral Webinars - Questions FINAL 4-28-16
Opioid Addiction Treatment ECHO, Virtual Learning Community – Satisfaction Survey New 200 24 0 Form 1 ECHO Survey.docx
Survey of Area Health Resource File Users (AHRF) New 100 7 0 Form and Instruction 1 AHRF User Survey
Title V Information System User Satisfaction Survey (TVIS) New 177 30 0 Form and Instruction 1 Screen Shots of Title V Information System
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 28391 5316 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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