HRSA Poison Help Campaign

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⚠️ Notice: This information collection may be referencing outdated material.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 HRSA Poison Help Campaign Form and Instruction
1 Moderator's Guide Moderator Guide for English Speaking.docx Form and Instruction
Moderator Guide for Spanish Speaking (in Spanish).docx Moderator Guide for Spanish Speaking IC Document
Screener for English Speaking.docx Screener for English Speaking IC Document
Screener for Spanish Speaking (in Spanish).docx Screener for Spanish Speaking IC Document
Connections Storyboard.pdf Connections Storyboard IC Document
Comparison Storyboard.pdf Comparison Storyboard IC Document
Supporting Statement.docx Supporting Statemen IC Document

Information Collection (IC) Details

IC Title:	HRSA Poison Help Campaign	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 and Instruction	1	Moderator's Guide	Moderator Guide for English Speaking.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 48	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	48	0	0	0	0	0
Annual IC Time Burden (Hours)	72	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Moderator Guide for Spanish Speaking	Moderator Guide for Spanish Speaking (in Spanish).docx	03/20/2013
Screener for English Speaking	Screener for English Speaking.docx	03/20/2013
Screener for Spanish Speaking	Screener for Spanish Speaking (in Spanish).docx	03/20/2013
Connections Storyboard	Connections Storyboard.pdf	03/20/2013
Comparison Storyboard	Comparison Storyboard.pdf	03/20/2013
Supporting Statemen	Supporting Statement.docx	03/20/2013

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