Survey on Gender, Ethnic and Racial Backgrounds of Clients and Staff at Bureau of Primary Health Care Supported Community-Based Health Service Sites

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6515	Survey on Gender, Ethnic and Racial Backgrounds of Clients and Staff at Bureau of Primary Health Care Supported Community-Based Health Service Sites	Form	Migrated

ICR Details

OMB Control No: 0915-0265	ICR Reference No: 200208-0915-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Survey on Gender, Ethnic and Racial Backgrounds of Clients and Staff at Bureau of Primary Health Care Supported Community-Based Health Service Sites
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/21/2002
	Date Received in OIRA: 08/15/2002
Terms of Clearance: Approved for use through 10/2003 under the following conditions: 1) HRSA amends its race/ethnicity questions to conform to OMB's 1997 Standards for the Classification of Federal Race/Ethnicity Data; 2) HRSA designs a representative subsample to examine the level of specificity and validity of race/ethnicity data reported by clinics. HRSA must share with OMB its design for this subsample and its strategy and timeframe for its fielding; 3) upon completion of this subsample, HRSA must report its findings to OMB for further input prior to resuming the survey effort. The interim report must include HRSA's detailed plans for tabulating the race/ethnicity data consistent with OMB Bulletin 00-002 Guidance for Aggregation; and 4) HRSA will continue to evaluate methods to compare the characteristics of clinic patients and staff to the broader service area populations.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2003	10/31/2003
Responses	11,250	0	0
Time Burden (Hours)	1,000	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The purpose of this study is to collect information on the gender, ethnic and racial composition of both clients and staff at BPHC supported health service sites.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Survey on Gender, Ethnic and Racial Backgrounds of Clients and Staff at Bureau of Primary Health Care Supported Community-Based Health Service Sites	HRSA-105, HRSA-106

---

ICR Summary of Burden

table that charts list 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	11,250	0	0	11,250	0	0
Annual Time Burden (Hours)	1,000	0	0	1,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

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: $0

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

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: 08/15/2002

---