BCRS Collegiate Health Service Corps 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⚠️ Notice: This information collection may be referencing outdated material.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 CHSC1 BCRS Collegiate Health Service Corps Survey Form
CHSC1 CHSC Survey AHECNATION_CHSC_Application.pdf Form
AHECNATION_CHSC_Application.jpg CHSC Survey Screenshots IC Document
BCRS-CHSC Survey-Draft-Supporting Statement-4.13.11.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	BCRS Collegiate Health Service Corps 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	CHSC1	CHSC Survey	AHECNATION_CHSC_Application.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	1,500	0	0	0	0	0
Annual IC Time Burden (Hours)	750	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CHSC Survey Screenshots	AHECNATION_CHSC_Application.jpg	10/21/2011
Supporting Statement	BCRS-CHSC Survey-Draft-Supporting Statement-4.13.11.docx	10/21/2011

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