Information Collection

HRSA Quality Toolkit Survey

IC 192572 under ICR 200904-0915-002 · OMB 0915-0212.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

HRSA Quality Toolkit Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.