Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Customer Survey	Form and Instruction	New	Available
Form 4 Online Focus Group Guide Nursing Prospective Applicants	Form and Instruction	New	Available
Form 3 Online Focus Group Guide Nursing Current Participants	Form and Instruction	New	Available
Form 2 In Person Moderator Guide Nurses Prospects Creative Exploratory	Form and Instruction	New	Available
Form 1 IDI Moderator Guide Nurses Administrators et al Creative Exploratory	Form and Instruction	New	Available
Form 4 Focus Group Guide	Form	New	Available
Form 3 Interview Guide	Form	New	Available
Form 2 Screener focusgroup	Form	New	Available
Form 1 Screener Interview	Form	New	Available
Form 1 ARF User Survey	Form	New	Available
Form 1 Customer Satisfaction Survey	Form	New	Available
Form CHSC1 CHSC Survey	Form	New	Available
Form PCRE-1 PCRE Survey - Eligible, Applied but not funded	Form	New	Available
Form 3 EPAT- Eligible No Inquiry Did Not Apply	Form	New	Available
Form 2 EPAT- Eligible Inquiry Did Not Apply	Form	New	Available
Form 1 EPAT Eligible Funded	Form	New	Available
Form PCRE-3 PCRE-Eligible No Inquiry Did Not Apply	Form	New	Available
Form PCRE-2 PCRE-Eligible Inquiry Did Not Apply	Form	New	Available
Form PCRE-1 PCRE Eligible Funded	Form	New	Available
Form Attachment D NHSC Brand Materials Survey	Form and Instruction	New	Available
Form Attachment A Focus Group Recruitment Screener	Form and Instruction	New	Available
Form Attachment B Focus Group Moderator's Guide	Form and Instruction	New	Available
Form Attachment C Consent Form	Form and Instruction	New	Available
Form QI 1 Quality Toolkit Survey	Form	New	Available
Form 001_OCIC 001_OCIC	Form and Instruction	New	Available
Form 001_WHUSA 001_WHUSA	Form and Instruction	New	Available
Form 001_CHUSA 001_CHUSA	Form and Instruction	New	Available
Form NFI 2009 NFI Survey	Form and Instruction	New	Available
ss 0212 partb.doc	Supporting Statement B	Uploaded 2009-04-13	Available
0212 focus issues.doc	Supplementary Document	Uploaded 2009-04-17	Available
OPA Survey.doc	Supplementary Document	Uploaded 2009-04-17	Available
nfi cust survey.doc	Supplementary Document	Uploaded 2009-04-17	Available
customer exec order.pdf	Supplementary Document	Uploaded 2009-04-13	Available
ss 0212.doc	Supporting Statement A	Uploaded 2009-04-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201754	OFAM Customer Satisfaction Survey	Form and Instruction	New	Customer Survey
201538	BCRS NELRP and NSP Focus Groups	Form and Instruction	New	Online Focus Group Guide Nursing Prospective Applicants
201538	BCRS NELRP and NSP Focus Groups	Form and Instruction	New	Online Focus Group Guide Nursing Current Participants
201538	BCRS NELRP and NSP Focus Groups	Form and Instruction	New	In Person Moderator Guide Nurses Prospects Creative Exploratory
201538	BCRS NELRP and NSP Focus Groups	Form and Instruction	New	IDI Moderator Guide Nurses Administrators et al Creative Exploratory
201008	HRSA Division of Transplantation Qualitative Assessment of Outreach Materials	Form	New	Focus Group Guide
201008	HRSA Division of Transplantation Qualitative Assessment of Outreach Materials	Form	New	Interview Guide
201008	HRSA Division of Transplantation Qualitative Assessment of Outreach Materials	Form	New	Screener focusgroup
201008	HRSA Division of Transplantation Qualitative Assessment of Outreach Materials	Form	New	Screener Interview
201008	HRSA Division of Transplantation Qualitative Assessment of Outreach Materials	Instruction	New
200840	Area Resource File User Survey	Form	New	ARF User Survey
200082	OFAM Grants Management Customer Service Survey	Form	New	Customer Satisfaction Survey
199895	BCRS Collegiate Health Service Corps Survey	Form	New	CHSC Survey
198838	BHPr Funding Strategy Evaluation - Applicants who did not receive funding	Form	New	PCRE Survey - Eligible, Applied but not funded
196219	BHPr Funding Strategy Evaluation- Expansion of Physician Assistant Training	Form	New	EPAT- Eligible No Inquiry Did Not Apply
196219	BHPr Funding Strategy Evaluation- Expansion of Physician Assistant Training	Form	New	EPAT- Eligible Inquiry Did Not Apply
196219	BHPr Funding Strategy Evaluation- Expansion of Physician Assistant Training	Form	New	EPAT Eligible Funded
195745	BHPr Funding Strategy Evaluation	Form	New	PCRE-Eligible No Inquiry Did Not Apply
195745	BHPr Funding Strategy Evaluation	Form	New	PCRE-Eligible Inquiry Did Not Apply
195745	BHPr Funding Strategy Evaluation	Form	New	PCRE Eligible Funded
193545	National Health Service Corps (NHSC) Brand and Materials Feedback	Form and Instruction	New	NHSC Brand Materials Survey
193545	National Health Service Corps (NHSC) Brand and Materials Feedback	Form and Instruction	New	Focus Group Recruitment Screener
193545	National Health Service Corps (NHSC) Brand and Materials Feedback	Form and Instruction	New	Focus Group Moderator's Guide
193545	National Health Service Corps (NHSC) Brand and Materials Feedback	Form and Instruction	New	Consent Form
193545	National Health Service Corps (NHSC) Brand and Materials Feedback	Other-Attachment E- Materials to be tested	New
192572	HRSA Quality Toolkit Survey	Form	New	Quality Toolkit Survey
192283	HRSA Information Center Live Help Online	Form and Instruction	New	001_OCIC
191193	Women's Health USA and Child Health USA User Satisfaction Surveys	Form and Instruction	New	001_WHUSA
191193	Women's Health USA and Child Health USA User Satisfaction Surveys	Form and Instruction	New	001_CHUSA
190524	New Freedom Initiative Caregiver Broadcast Survey	Form and Instruction	New	NFI Survey

ICR Details

OMB Control No: 0915-0212	ICR Reference No: 200904-0915-002
Status: Historical Active	Previous ICR Reference No: 200809-0915-001
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: 08/14/2009
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/27/2009
Terms of Clearance: Previous terms of clearance remain in effect.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2012	36 Months From Approved	08/31/2009
Responses	52,050	0	52,050
Time Burden (Hours)	5,075	0	5,075
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 23472	04/30/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 18726	04/24/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 14

table that charts list of burden

IC Title	Form No.	Form Name
Area Resource File User Survey	1	ARF User Survey
BCRS Collegiate Health Service Corps Survey	CHSC1	CHSC Survey
BCRS NELRP and NSP Focus Groups	1, 2, 3, 4	IDI Moderator Guide Nurses Administrators et al Creative Exploratory ,   In Person Moderator Guide Nurses Prospects Creative Exploratory ,   Online Focus Group Guide Nursing Current Participants ,   Online Focus Group Guide Nursing Prospective Applicants
BHPr Funding Strategy Evaluation	PCRE-1, PCRE-2, PCRE-3	PCRE Eligible Funded ,   PCRE-Eligible Inquiry Did Not Apply ,   PCRE-Eligible No Inquiry Did Not Apply
BHPr Funding Strategy Evaluation - Applicants who did not receive funding	PCRE-1	PCRE Survey - Eligible, Applied but not funded
BHPr Funding Strategy Evaluation- Expansion of Physician Assistant Training	1, 2, 3	EPAT Eligible Funded ,   EPAT- Eligible Inquiry Did Not Apply ,   EPAT- Eligible No Inquiry Did Not Apply
HRSA Division of Transplantation Qualitative Assessment of Outreach Materials	1, 2, 3, 4	Screener Interview ,   Screener focusgroup ,   Interview Guide ,   Focus Group Guide
HRSA Information Center Live Help Online	001_OCIC	001_OCIC
HRSA Quality Toolkit Survey	QI 1	Quality Toolkit Survey
National Health Service Corps (NHSC) Brand and Materials Feedback	Attachment C, Attachment B, Attachment A, Attachment D	Consent Form ,   Focus Group Moderator's Guide ,   Focus Group Recruitment Screener ,   NHSC Brand Materials Survey
New Freedom Initiative Caregiver Broadcast Survey	NFI 2009	NFI Survey
OFAM Customer Satisfaction Survey	1	Customer Survey
OFAM Grants Management Customer Service Survey	1	Customer Satisfaction Survey
Women's Health USA and Child Health USA User Satisfaction Surveys	001_CHUSA, 001_WHUSA	001_CHUSA ,   001_WHUSA

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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	52,050	52,050	0	0	0	0
Annual Time Burden (Hours)	5,075	5,075	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:

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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)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 04/27/2009

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