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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Confirmatory Typing Survey	Form and Instruction	New	Available
Form 1 Regions IV and VI Infant Mortality CoIIN Participant Satisfaction Survey	Form and Instruction	New	Available
Form 1 Maternal and Child Health Epidemiology Training Course One-Year Follow-up Survey	Form	New	Available
Form 2 Usability Testing Survey-IQRS Form	Form	New	Available
Form 1 Usability Testing Survey-Website Form	Form	New	Available
Form 1 AREWare customer/user satisfaction	Form and Instruction	New	Available
Form 2 non-comprehensive site visit	Form	New	Available
Form 1 Comprehensive Site Visit	Form	New	Available
Form 1 Moderator's Guide	Form and Instruction	New	Available
Form 1 customer satisfaction survey	Form and Instruction	New	Available
Form 1 NACCHO MAPP training satisfaction survey	Form	New	Available
Form 1 TACC Needs Assessment	Form and Instruction	New	Available
Form 1 PCFDI	Form	New	Available
Form 2 Participant Survey	Form and Instruction	New	Available
Form 1 Site Feedback	Form and Instruction	New	Available
Form 2 Participant Feedback	Form and Instruction	New	Available
Form 1 Site Feedback	Form and Instruction	New	Available
Form D Form D Follow-Up Form For Community Event Participant 7-17	Form and Instruction	New	Available
Form C Form C For participants in Community_Events_7-17	Form and Instruction	New	Available
Form B Form B Follow-Up Form For Participants in the Bullying Prevention Training Module 7-17	Form and Instruction	New	Available
Form A Form A For Participants in the Bullying Prevention Modules Training 7 17	Form and Instruction	New	Available
Supporting Statement - part B.docx	Supporting Statement B	Uploaded 2012-05-22	Available
Example Customer Survey OFAM.pdf	Supplementary Document	Uploaded 2012-05-22	Available
Example Focus Group HSB.docx	Supplementary Document	Uploaded 2012-05-22	Available
Example Customer Survey BHPr.pdf	Supplementary Document	Uploaded 2012-05-22	Available
Supporting Statement - part A (REVISED).docx	Supporting Statement A	Uploaded 2012-07-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
215329	Confirmatory Typing Survey	Form and Instruction	New	Confirmatory Typing Survey
212594	Regions IV VI Infant Mortality Collaborative Improvement and Innovation Network (CoIIN) Participant Satisfaction Survey	Form and Instruction	New	Regions IV and VI Infant Mortality CoIIN Participant Satisfaction Survey
212431	Maternal and Child Health Epidemiology Training Course One-Year Follow-up Survey	Form	New	Maternal and Child Health Epidemiology Training Course One-Year Follow-up Survey
210508	DPDB Usability Studies	Form	New	Usability Testing Survey-IQRS Form
210508	DPDB Usability Studies	Form	New	Usability Testing Survey-Website Form
210134	CAREWare customer/user satisfaction	Form and Instruction	New	AREWare customer/user satisfaction
207948	Technical Assistance provided to Ryan White HIV/AIDS Program Grantees	Form	New	non-comprehensive site visit
207948	Technical Assistance provided to Ryan White HIV/AIDS Program Grantees	Form	New	Comprehensive Site Visit
206222	HRSA Poison Help Campaign	Form and Instruction	New	Moderator's Guide
206104	Customer Satisfaction Feedback of MIECHV Post-Award Grant Monitoring Process	Form and Instruction	New	customer satisfaction survey
206082	MAPP Satisfaction Survey	Form	New	NACCHO MAPP training satisfaction survey
206018	MIECHV TACC Needs Assessment Survey	Form and Instruction	New	TACC Needs Assessment
205935	Primary Care Faculty Development Initiative	Form	New	PCFDI
204922	NHSC Virtual Job Fair Customer Feedback	Form and Instruction	New	Participant Survey
204922	NHSC Virtual Job Fair Customer Feedback	Form and Instruction	New	Site Feedback
203969	National Health Service Corps (NHSC) Virtual Job Fair Customer Feedback	Form and Instruction	New	Participant Feedback
203969	National Health Service Corps (NHSC) Virtual Job Fair Customer Feedback	Form and Instruction	New	Site Feedback
203347	Bullying Prevention Training Modules Feedback Forms	Form and Instruction	New	Form D Follow-Up Form For Community Event Participant 7-17
203347	Bullying Prevention Training Modules Feedback Forms	Form and Instruction	New	Form C For participants in Community_Events_7-17
203347	Bullying Prevention Training Modules Feedback Forms	Form and Instruction	New	Form B Follow-Up Form For Participants in the Bullying Prevention Training Module 7-17
203347	Bullying Prevention Training Modules Feedback Forms	Form and Instruction	New	Form A For Participants in the Bullying Prevention Modules Training 7 17

ICR Details

OMB Control No: 0915-0212	ICR Reference No: 201206-0915-002
Status: Historical Active	Previous ICR Reference No: 200904-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/16/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/08/2012
Terms of Clearance: The agency is reminded that individual packages submitted under this generic clearance must be reviewed and approved by OMB prior to fielding. OMB will seek to review surveys within 10 days of submission. Packages submitted under this clearance will be used solely for purposes of measuring customer satisfaction.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2015	36 Months From Approved	08/31/2012
Responses	52,250	0	52,050
Time Burden (Hours)	5,375	0	5,075
Cost Burden (Dollars)	0	0	0

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Abstract: This generic project clearance allows HRSA to conduct voluntary customer satisfaction surveys of its partners to assess strengths and weaknesses in program services and products. Examples of such surveys include satisfaction with technical assistance provided to grantees, in class evaluations of training sessions, and satisfaction with information services.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

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:
	77 FR 15111	03/14/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 33224	06/05/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 14

table that charts list of burden

IC Title	Form No.	Form Name
Bullying Prevention Training Modules Feedback Forms	A, B, C, D	Form A For Participants in the Bullying Prevention Modules Training 7 17 ,   Form B Follow-Up Form For Participants in the Bullying Prevention Training Module 7-17 ,   Form C For participants in Community_Events_7-17 ,   Form D Follow-Up Form For Community Event Participant 7-17
CAREWare customer/user satisfaction	1	AREWare customer/user satisfaction
Confirmatory Typing Survey	1	Confirmatory Typing Survey
Customer Satisfaction Feedback of MIECHV Post-Award Grant Monitoring Process	1	customer satisfaction survey
DPDB Usability Studies	1, 2	Usability Testing Survey-Website Form ,   Usability Testing Survey-IQRS Form
HRSA Poison Help Campaign	1	Moderator's Guide
MAPP Satisfaction Survey	1	NACCHO MAPP training satisfaction survey
MIECHV TACC Needs Assessment Survey	1	TACC Needs Assessment
Maternal and Child Health Epidemiology Training Course One-Year Follow-up Survey	1	Maternal and Child Health Epidemiology Training Course One-Year Follow-up Survey
NHSC Virtual Job Fair Customer Feedback	1, 2	Site Feedback ,   Participant Survey
National Health Service Corps (NHSC) Virtual Job Fair Customer Feedback	2, 1	Site Feedback ,   Participant Feedback
Primary Care Faculty Development Initiative	1	PCFDI
Regions IV VI Infant Mortality Collaborative Improvement and Innovation Network (CoIIN) Participant Satisfaction Survey	1	Regions IV and VI Infant Mortality CoIIN Participant Satisfaction Survey
Technical Assistance provided to Ryan White HIV/AIDS Program Grantees	1, 2	Comprehensive Site Visit ,   non-comprehensive site visit

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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	52,250	52,050	0	200	0	0
Annual Time Burden (Hours)	5,375	5,075	0	300	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: HRSA's renewal request includes the same number of burden hours for surveys and in-class evaluations as requested in the previous submission, which was approved by OMB. We are currently requesting to increase the number of focus group burden hours to accommodate new programs (mostly due to the Affordable Care Act) that would most appropriately be evaluated through the use or inclusion of focus groups within prospective evaluation data collection activities.

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Annual Cost to Federal Government: $700,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 06/08/2012

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