National Health Service Corps (NHSC) Brand and Materials Feedback

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⚠️ Notice: This information collection may be referencing outdated material.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 Attachment B National Health Service Corps (NHSC) Brand and Materials Feedback Form and Instruction
Attachment E NHSC Brand_Materials Testing Items to be Tested FINAL 6 24 10.docx Other-Attachment E- Materials to be
Attachment C Consent Form Attachment C NHSC Brand_Materials Testing FGs Consent Form FINAL 6 28 10.docx Form and Instruction
Attachment B Focus Group Moderator's Guide Attachment B NHSC Brand_Materials Testing FG Mod Guide FINAL 6 28 10.docx Form and Instruction
Attachment A Focus Group Recruitment Screener Attachment A NHSC Brand_Materials Testing FG Screener FINAL 6 28 10.docx Form and Instruction
Attachment D NHSC Brand Materials Survey Attachment D NHSC Brand_Materials Testing Online Survey FINAL 6 24 10.docx Form and Instruction
OMB Supporting Statement_NHSC Brand_Materials Feedback FINAL 6 28 10.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	National Health Service Corps (NHSC) Brand and Materials Feedback	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Attachment B	Focus Group Moderator's Guide	Attachment B NHSC Brand_Materials Testing FG Mod Guide FINAL 6 28 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment A	Focus Group Recruitment Screener	Attachment A NHSC Brand_Materials Testing FG Screener FINAL 6 28 10.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment D	NHSC Brand Materials Survey	Attachment D NHSC Brand_Materials Testing Online Survey FINAL 6 24 10.docx	Yes	Yes	Fillable Fileable
Other-Attachment E- Materials to be tested			Attachment E NHSC Brand_Materials Testing Items to be Tested FINAL 6 24 10.docx	Yes	No	Printable Only
Form and Instruction	Attachment C	Consent Form	Attachment C NHSC Brand_Materials Testing FGs Consent Form FINAL 6 28 10.docx	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 294	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	294	0	0	0	0	0
Annual IC Time Burden (Hours)	141	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	OMB Supporting Statement_NHSC Brand_Materials Feedback FINAL 6 28 10.docx	06/28/2010

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