Pilot Test of the Community Health Center/National Health Service Corp User/Visit Survey

ICR 200012-0915-001

OMB: 0915-0185

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0915-0185 200012-0915-001
Historical Active 199410-0915-001
HHS/HSA
Pilot Test of the Community Health Center/National Health Service Corp User/Visit Survey
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 04/04/2001
Retrieve Notice of Action (NOA) 12/06/2000
Approved consistent with changes detailed in memos dated 3/22/01 and 3/26/01, including the assurance that race/ethnicity questions will conform to OMB guidelines. Additionally, as per the conference call of 3/19/01, the pilot study methodology will not contain a prospective design. This clearance is only an approval of the standard retrospective design similar to the design used in past studies. Any changes to the methodology for the pilot test must go through further OMB clearance. The full-scale study must be approved under a seperate clearance.
  Inventory as of this Action Requested Previously Approved
04/30/2004 04/30/2004
550 0 0
343 0 0
0 0 0

The purpose of this collection is to pilot test the User Visit Survey to determine the optimal sampling methodology, e.g. retrospective of prospective and assess the user questionnaire.

None
None


No

1
IC Title Form No. Form Name
Pilot Test of the Community Health Center/National Health Service Corp User/Visit Survey

  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 550 0 0 550 0 0
Annual Time Burden (Hours) 343 0 0 343 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
Yes Part B of Supporting Statement
No
Uncollected
Uncollected
Uncollected
Uncollected

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
12/06/2000


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