Bullying Prevention Training Modules Feedback Forms

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⚠️ Notice: This information collection may be referencing outdated material.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 Bullying Prevention Training Modules Feedback Forms Form and Instruction
1 Form A Bullying Prevention Online Program - 06232015.doc Form A Bullying Prevention Online Program - 06232015.docx Form and Instruction
2 Form B Follow-Up Form For Participants in the Bullying P Form B Follow-Up Form For Participants in the Bullying Prevention Training Module 06232015.docx Form and Instruction
RevisedHRSA Bullying Supporting Statement 062315.docx RevisedHRSA Bullying Supporting Statement 062315.docx IC Document

Information Collection (IC) Details

IC Title:	Bullying Prevention Training Modules Feedback Forms	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	Form A Bullying Prevention Online Program - 06232015.docx	Form A Bullying Prevention Online Program - 06232015.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	Form B Follow-Up Form For Participants in the Bullying Prevention Training Module	Form B Follow-Up Form For Participants in the Bullying Prevention Training Module 06232015.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
RevisedHRSA Bullying Supporting Statement 062315.docx	RevisedHRSA Bullying Supporting Statement 062315.docx	07/28/2015

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