National Health Service Corps Site Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form 1 National Health Service Corps Site Survey	Form and Instruction	Modified	Available
NHSC Site Survey 2011 Screen Shots (2).docx	Supplementary Document	Uploaded 2011-12-07	Available
OMB_NHSC Site Survey_SupportingStmt_12022011 FINAL.docx	Supporting Statement A	Uploaded 2011-12-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6473	National Health Service Corps Site Survey	Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0232	ICR Reference No: 201112-0915-003
Status: Historical Active	Previous ICR Reference No: 200810-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: National Health Service Corps Site Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/10/2012
	Date Received in OIRA: 12/12/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2015	36 Months From Approved	04/30/2012
Responses	1,200	0	1,200
Time Burden (Hours)	32,400	0	32,400
Cost Burden (Dollars)	105,000	0	105,000

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Abstract: The National Health Service Corp Site Survey, formerly known as the Uniform Data System (UDS) Report, will establish continuity for Bureau supported grant/non-grant health care delivery sites. The collection of client and services data from non-grant suported sites will facilitate mandated reporting for NHSC activities.

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Authorizing Statute(s): US Code: 42 USC 338C Name of Law: Public Health Service Act
   US Code: 42 USC 338D Name of Law: Public Health Service Act
   US Code: 42 USC 333A Name of Law: Public Health Service Act
   US Code: 42 USC 331 Name of Law: Public Health Service Act
   US Code: 42 USC 333-335 Name of Law: Public Health Service Act
  

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:
	76 FR 53478	08/26/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 73651	11/29/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
National Health Service Corps Site Survey	Form 1	NHSC Site Survey

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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	1,200	1,200	0	0	0	0
Annual Time Burden (Hours)	32,400	32,400	0	0	0	0
Annual Cost Burden (Dollars)	105,000	105,000	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: $59,117

Does this IC contain surveys, censuses, or employ statistical methods? No

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 12/12/2011

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