HRSA Quality Toolkit Survey

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Document Name Document Type
Form QI 1 HRSA Quality Toolkit Survey Form
QI 1 Quality Toolkit Survey Survey Tool.docx Form
customer_survey_Quality toolkit 2010.docx Supporting Statement IC Document
Revised 6 4 10-customer_survey_Quality toolkit 2010.docx Revised Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	HRSA Quality Toolkit Survey	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	QI 1	Quality Toolkit Survey	Survey Tool.docx		No	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	750	750
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	customer_survey_Quality toolkit 2010.docx	04/12/2010
Revised Supporting Statement	Revised 6 4 10-customer_survey_Quality toolkit 2010.docx	06/07/2010

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