View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Health Center Workforce Well-Being Survey: Cognitive Sessions	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

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	1	Cognitive Interview Informed Consent	Cognitive Interview Informed Consent_1.6.2020 Submission.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 60

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	60	0	60	0	0	0
Annual IC Time Burden (Hours)	90	0	90	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	Cognitive Interview Supporting Statement A_1.6.2020 Submission.docx	03/03/2021
Supporting Statement B	Cognitive Interview Supporting Statement B 12292020.docx	03/03/2021
HRSA Survey Draft	HRSA Survey Draft V4__2.16.21 FINAL.docx	03/03/2021

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