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

Forms and Documents

Document	Type	Status	Availability
Form 1 DATA CoIIN	Form	New	Available
Form 1 MCH Connects Survey	Form and Instruction	New	Available
Form 1 Data and Technical Assistance (DATA) Task Order to Support the Infant Mortality CoIIN	Form	New	Available
Form 1 Opioid Addiction Treatment ECHO, Virtual Learning Community – Satisfaction Survey	Form	New	Available
Form 1 HRSA Office of Acquisition Management and Policy (OAMP) Customer Satisfaction Survey	Form	New	Available
Form 1 NHSC Virtual Job Fair Customer Feedback	Form and Instruction	New	Available
Form 1 HRSA Office of Regional Operations (ORO) Outreach & Education Generic Survey Tool	Form	New	Available
Form 2 Discussions on 50+ Donors	Form and Instruction	New	Available
Form 1 HRSA Electronic Handbooks Customer Service Survey	Form	New	Available
Form A Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Form and Instruction	New	Available
Form 1 ORO Dallas State Strategic Partnership Forum	Form and Instruction	New	Available
Form 1 BPHC Customer Service Survey Helpline & Answers	Form	New	Available
Form 1 MCH Leadership Competencies	Form and Instruction	New	Available
Form 1 2016 National Ryan White Conference on HIV Care and Treatment Conference Evaluation	Form and Instruction	New	Available
Form 1 Maternal and Child Health Epidemiology Training Course - One Year Follow-Up Survey	Form	New	Available
Form 1 Discussion on Teen Organ Donors	Form and Instruction	New	Available
Form B Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Feedback and Satisfaction Surveys	Form and Instruction	New	Available
Form 1 Office of Regional Operations (ORO) 2016 Tele-Behavioral Health Webcase Series	Form	New	Available
Form 1 ORO-Dallas Virtual Participant Satisfaction Survey	Form and Instruction	New	Available
Form 1 HRSA, ACF, and HHS OWH Pilot on Intimate Partner Violence (IPV) Screening and Counseling in Health Centers and Domestic Violence Partner Organizations	Form and Instruction	New	Available
Form 1 Survey of Area Health Resource File Users (AHRF)	Form and Instruction	New	Available
Form 1 HRSA Survey Assessment of Objective Peer Review	Form	New	Available
Form 1 DPDB Usability Surveys	Form	New	Available
Form 1 Bullying Prevention Training Modules Feedback Forms	Form and Instruction	New	Available
Form 1 Title V Information System User Satisfaction Survey (TVIS)	Form and Instruction	New	Available
Form 1 Customer Satisfaction Surveys for the Health Literacy Training Program	Form	New	Available
Form 2 HRSA Division of Transplanation (DoT Research on Customer Information Needs Related to Vascularized Composite Allographs Transplants	Form and Instruction	New	Available
Supporting Statement - part A.docx	Supporting Statement A	Uploaded 2015-03-03	Available
Supporting Statement - part B.docx	Supporting Statement B	Uploaded 2015-03-03	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

IC Document Collections

IC ID	Collection	Type	Status	Form
231331	DATA CoIIN	Form	New
231166	MCH Connects Survey	Form and Instruction	New
230710	Data and Technical Assistance (DATA) Task Order to Support the Infant Mortality CoIIN	Form	New
228714	Opioid Addiction Treatment ECHO, Virtual Learning Community – Satisfaction Survey	Form	New
227313	HRSA Office of Acquisition Management and Policy (OAMP) Customer Satisfaction Survey	Form	New
227253	NHSC Virtual Job Fair Customer Feedback	Form and Instruction	New
226674	HRSA Office of Regional Operations (ORO) Outreach & Education Generic Survey Tool	Form	New
226490	Discussions on 50+ Donors	Form and Instruction	New
226290	HRSA Electronic Handbooks Customer Service Survey	Form	New
225692	Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Form and Instruction	New
223439	ORO Dallas State Strategic Partnership Forum	Form and Instruction	New
223191	BPHC Customer Service Survey Helpline & Answers	Form	New
223002	MCH Leadership Competencies	Form and Instruction	New
222522	2016 National Ryan White Conference on HIV Care and Treatment Conference Evaluation	Form and Instruction	New
222409	Maternal and Child Health Epidemiology Training Course - One Year Follow-Up Survey	Form	New
221887	Discussion on Teen Organ Donors	Form and Instruction	New
221518	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Feedback and Satisfaction Surveys	Form and Instruction	New
221444	Office of Regional Operations (ORO) 2016 Tele-Behavioral Health Webcase Series	Form	New
220987	ORO-Dallas Virtual Participant Satisfaction Survey	Form and Instruction	New
220598	HRSA, ACF, and HHS OWH Pilot on Intimate Partner Violence (IPV) Screening and Counseling in Health Centers and Domestic Violence Partner Organizations	Form and Instruction	New
218350	Survey of Area Health Resource File Users (AHRF)	Form and Instruction	New
217944	HRSA Survey Assessment of Objective Peer Review	Form	New
217730	DPDB Usability Surveys	Form	New
217671	Bullying Prevention Training Modules Feedback Forms	Form and Instruction	New
217437	Title V Information System User Satisfaction Survey (TVIS)	Form and Instruction	New
217329	Customer Satisfaction Surveys for the Health Literacy Training Program	Form	New
216834	HRSA Division of Transplanation (DoT Research on Customer Information Needs Related to Vascularized Composite Allographs Transplants	Form and Instruction	New

ICR Details

OMB Control No: 0915-0212	ICR Reference No: 201502-0915-002
Status: Historical Active	Previous ICR Reference No: 201206-0915-002
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: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/08/2015
	Date Received in OIRA: 03/12/2015
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.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	36 Months From Approved	07/31/2015
Responses	52,250	0	52,250
Time Burden (Hours)	5,375	0	5,375
Cost Burden (Dollars)	0	0	0

---

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.

---

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

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 75164	12/17/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 12179	03/06/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 27

IC Title	Form No.	Form Name
Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Feedback and Satisfaction Surveys	D, E, B, C	Attachement B - Town Hall Satisfaction Survey ,   Attachment C - All Grantee Meeting Assessment Form Individual Session ,   Attachment D - All Grantee Meeting Assessment Form Overall ,   Attachment E - Site Visit Assessment Form
DPDB Usability Surveys	1, 2	NPDB System Form ,   NPDB Website Form
HRSA Survey Assessment of Objective Peer Review	1, 2	Reviewer Survey ,   Chair Survey
Maternal and Child Health Epidemiology Training Course - One Year Follow-Up Survey	1	One-Year Trainee Survey form
DATA CoIIN	1	DATA CoIIN_Platform Training Survey_042018.pdf
ORO-Dallas Virtual Participant Satisfaction Survey	1	ORO Dallas Virtual Participant Satisfaction Survey
HRSA Electronic Handbooks Customer Service Survey	1	HRSA EHBs Survey Screenshot
Discussions on 50+ Donors	3, 2, 5, 6	20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx ,   20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx ,   20170303 Attachment 5__FocusGroup_ParticipantScreener (EP_DoT) CLEAN.docx ,   20170303 Attachment 6__Survey _Screener Questionnaire - Rd 2 CLEAN Rd 2.docx
HRSA Office of Regional Operations (ORO) Outreach & Education Generic Survey Tool	1	ORO Generic Evaluation Survey January 2017 - FINAL DRAFT.docx
MCH Connects Survey	1	MCH Connects 3 Month Survey- FINAL.docx
Bullying Prevention Training Modules Feedback Forms	2, 1	Form A Bullying Prevention Online Program - 06232015.docx ,   Form B Follow-Up Form For Participants in the Bullying Prevention Training Module
HRSA, ACF, and HHS OWH Pilot on Intimate Partner Violence (IPV) Screening and Counseling in Health Centers and Domestic Violence Partner Organizations	6a, 7a, 3, 2, 1, 4, 5, 6b, 7b	Training Survey for Health Organizations ,   Follow Up Training Survey for Health Organizations ,   Advocate - Provider 6 Month Follow Up Survey for Health Organizations ,   Collaborative Behavior Survey ,   Health Care Response to Domestic Violence Quality Assessment Program Improvement Tool ,   HRSA Patient Feedback Survey - English.docx ,   HRSA Patient Feedback Survey - Spanish ,   Client Feedback Survey - English ,   Client Feedback Survey - Spanish
MCH Leadership Competencies	1	Grantee Survey
Discussion on Teen Organ Donors	1, 2, 3	Attachment 1 Focus Group Informed Consent ,   Attachment 2 Focus Group Participant Screener ,   Attachment 4 Survey Screener and Questionnaire
Customer Satisfaction Surveys for the Health Literacy Training Program	1, 2	Health Literacy Training for Health Professionals Customer Satisfaction Survey ,   Health Literacy Training of Trainers Customer Satisfaction Survey
Office of Regional Operations (ORO) 2016 Tele-Behavioral Health Webcase Series	1	Telebehavioral Webinars - Questions FINAL 4-28-16
Opioid Addiction Treatment ECHO, Virtual Learning Community – Satisfaction Survey	1	ECHO Survey.docx
HRSA Division of Transplanation (DoT Research on Customer Information Needs Related to Vascularized Composite Allographs Transplants	2, 1	Survey on VCA Donation ,   Focus Groups on VCA Donation
2016 National Ryan White Conference on HIV Care and Treatment Conference Evaluation	1	Overall 2016 RW Conference Meeting Evaluation
ORO Dallas State Strategic Partnership Forum	1	Regional and State Strategic Partnership Forum Form
Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	A, B, C, D	Attachment A -Webinar Customer Satisfaction Survey ,   Attachment B - Targeted TA CoP Customer Satisfaction Survey ,   Attachment C - Newsletter Issue Brief Groupsite Customer Satisfaction Survey ,   Attachment D - Annual Satisfaction Survey
HRSA Office of Acquisition Management and Policy (OAMP) Customer Satisfaction Survey	1	Example Survey in Survey Monkey.pdf
Title V Information System User Satisfaction Survey (TVIS)	1	Screen Shots of Title V Information System
Survey of Area Health Resource File Users (AHRF)	1	AHRF User Survey
BPHC Customer Service Survey Helpline & Answers	2, 1	Survey Instrument Helpline ,   Survey Instrument Answers
NHSC Virtual Job Fair Customer Feedback	4, 3, 1, 2	NHSC Virtual Job Fair SITES Feedback Questions.docx ,   NHSC Virtual Job Fair PARTICIPANTS Feedback Questions.docx ,   NHSC Virtual Job Fair SITES Follow Up Feedback Questions.docx ,   NHSC Virtual Job Fair PARTICIPANTS Follow Up Feedback Questions.docx
Data and Technical Assistance (DATA) Task Order to Support the Infant Mortality CoIIN	1, 2, 3	DATA CoIIN_ Post-TA Webinar Evaluation Survey.pdf ,   DATA CoIIN_Post-Stakeholder Webinar Evaluation Survey.pdf ,   DATA CoIIN_Web-based Shared workspace/Online Platform Survey.pdf

---

ICR Summary 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	52,250	0	0	0	0
Annual Time Burden (Hours)	5,375	5,375	0	0	0	0
Annual Cost Burden (Dollars)	0	0	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:

---

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

---

Common Form ICR:  No

---

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: 03/12/2015

---