Primary Care Faculty Development Initiative

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⚠️ Notice: This information collection may be referencing outdated material.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 1 Primary Care Faculty Development Initiative Form
1 PCFDI 3PCFDI Post Program Survey.docx Form
OMB Supporting Statement PCFDI.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Primary Care Faculty Development Initiative	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	1	PCFDI	3PCFDI Post Program Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36	Number of Respondents for Small Entity: 36

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	36	0	0	0	0	0
Annual IC Time Burden (Hours)	6	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 PCFDI.docx	02/25/2013

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