View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View Generic ICR - OIRA Conclusion
OMB Control No:
0915-0212
ICR Reference No:
201502-0915-002
Status:
Historical Active
Previous ICR Reference No:
201206-0915-002
Agency/Subagency:
HHS/HSA
Agency Tracking No:
Title:
Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration
Type of Information Collection:
Extension without change of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
05/08/2015
Retrieve Notice of Action (NOA)
Date Received in OIRA:
03/12/2015
Terms of Clearance:
The agency is reminded that individual packages submitted under this generic clearance must be reviewed and approved by OMB prior to fielding. OMB will seek to review surveys within 10 days of submission. Packages submitted under this clearance will be used solely for purposes of measuring customer satisfaction.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2018
36 Months From Approved
07/31/2015
Responses
52,250
0
52,250
Time Burden (Hours)
5,375
0
5,375
Cost Burden (Dollars)
0
0
0
Abstract:
This generic project clearance allows HRSA to conduct voluntary customer satisfaction surveys of its partners to assess strengths and weaknesses in program services and products. Examples of such surveys include satisfaction with technical assistance provided to grantees, in class evaluations of training sessions, and satisfaction with information services.
Authorizing Statute(s):
EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
79 FR 75164
12/17/2014
30-day Notice:
Federal Register Citation:
Citation Date:
80 FR 12179
03/06/2015
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
27
IC Title
Form No.
Form Name
2016 National Ryan White Conference on HIV Care and Treatment Conference Evaluation
1
Overall 2016 RW Conference Meeting Evaluation
BPHC Customer Service Survey Helpline & Answers
2, 1
Survey Instrument Helpline
,
Survey Instrument Answers
Bullying Prevention Training Modules Feedback Forms
2, 1
Form A Bullying Prevention Online Program - 06232015.docx
,
Form B Follow-Up Form For Participants in the Bullying Prevention Training Module
Customer Satisfaction Surveys for the Health Literacy Training Program
1, 2
Health Literacy Training for Health Professionals Customer Satisfaction Survey
,
Health Literacy Training of Trainers Customer Satisfaction Survey
DATA CoIIN
1
DATA CoIIN_Platform Training Survey_042018.pdf
DPDB Usability Surveys
1, 2
NPDB System Form
,
NPDB Website Form
Data and Technical Assistance (DATA) Task Order to Support the Infant Mortality CoIIN
1, 2, 3
DATA CoIIN_ Post-TA Webinar Evaluation Survey.pdf
,
DATA CoIIN_Post-Stakeholder Webinar Evaluation Survey.pdf
,
DATA CoIIN_Web-based Shared workspace/Online Platform Survey.pdf
Discussion on Teen Organ Donors
1, 2, 3
Attachment 1 Focus Group Informed Consent
,
Attachment 2 Focus Group Participant Screener
,
Attachment 4 Survey Screener and Questionnaire
Discussions on 50+ Donors
3, 2, 5, 6
20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx
,
20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx
,
20170303 Attachment 5__FocusGroup_ParticipantScreener (EP_DoT) CLEAN.docx
,
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
2, 1
Focus Groups on VCA Donation
,
Survey on VCA Donation
HRSA Electronic Handbooks Customer Service Survey
1
HRSA EHBs Survey Screenshot
HRSA Office of Acquisition Management and Policy (OAMP) Customer Satisfaction Survey
1
Example Survey in Survey Monkey.pdf
HRSA Office of Regional Operations (ORO) Outreach & Education Generic Survey Tool
1
ORO Generic Evaluation Survey January 2017 - FINAL DRAFT.docx
HRSA Survey Assessment of Objective Peer Review
1, 2
Reviewer Survey
,
Chair Survey
HRSA, ACF, and HHS OWH Pilot on Intimate Partner Violence (IPV) Screening and Counseling in Health Centers and Domestic Violence Partner Organizations
6a, 7a, 3, 2, 1, 4, 5, 6b, 7b
Training Survey for Health Organizations
,
Follow Up Training Survey for Health Organizations
,
Advocate - Provider 6 Month Follow Up Survey for Health Organizations
,
Collaborative Behavior Survey
,
Health Care Response to Domestic Violence Quality Assessment Program Improvement Tool
,
HRSA Patient Feedback Survey - English.docx
,
HRSA Patient Feedback Survey - Spanish
,
Client Feedback Survey - English
,
Client Feedback Survey - Spanish
MCH Connects Survey
1
MCH Connects 3 Month Survey- FINAL.docx
MCH Leadership Competencies
1
Grantee Survey
Maternal and Child Health Epidemiology Training Course - One Year Follow-Up Survey
1
One-Year Trainee Survey form
Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys
A, B, C, D
Attachment A -Webinar Customer Satisfaction Survey
,
Attachment B - Targeted TA CoP Customer Satisfaction Survey
,
Attachment C - Newsletter Issue Brief Groupsite Customer Satisfaction Survey
,
Attachment D - Annual Satisfaction Survey
Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Feedback and Satisfaction Surveys
D, E, B, C
Attachement B - Town Hall Satisfaction Survey
,
Attachment C - All Grantee Meeting Assessment Form Individual Session
,
Attachment D - All Grantee Meeting Assessment Form Overall
,
Attachment E - Site Visit Assessment Form
NHSC Virtual Job Fair Customer Feedback
4, 3, 1, 2
NHSC Virtual Job Fair SITES Feedback Questions.docx
,
NHSC Virtual Job Fair PARTICIPANTS Feedback Questions.docx
,
NHSC Virtual Job Fair SITES Follow Up Feedback Questions.docx
,
NHSC Virtual Job Fair PARTICIPANTS Follow Up Feedback Questions.docx
ORO Dallas State Strategic Partnership Forum
1
Regional and State Strategic Partnership Forum Form
ORO-Dallas Virtual Participant Satisfaction Survey
1
ORO Dallas Virtual Participant Satisfaction Survey
Office of Regional Operations (ORO) 2016 Tele-Behavioral Health Webcase Series
1
Telebehavioral Webinars - Questions FINAL 4-28-16
Opioid Addiction Treatment ECHO, Virtual Learning Community – Satisfaction Survey
1
ECHO Survey.docx
Survey of Area Health Resource File Users (AHRF)
1
AHRF User Survey
Title V Information System User Satisfaction Survey (TVIS)
1
Screen Shots of Title V Information System
ICR Summary of Burden
Total Approved
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
52,250
52,250
0
0
0
0
Annual Time Burden (Hours)
5,375
5,375
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:
Annual Cost to Federal Government:
$700,000
Does this IC contain surveys, censuses, or employ statistical methods?
Yes
Part B of Supporting Statement
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
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?
Uncollected
Agency Contact:
Jodi Duckhorn 301 443-1984
Common Form ICR:
No
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:
03/12/2015
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