ORO Dallas State Strategic Partnership Forum

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⚠️ Notice: This information collection may be referencing outdated material.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 ORO Dallas State Strategic Partnership Forum Form and Instruction
1 Regional and State Strategic Partnership Forum Form Regional and State Strategic Partnership Forum Form.docx Form and Instruction
Justification - State Strategic Partnership Forum Evaluation Generic Clearance.docx Draft 1.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	ORO Dallas State Strategic Partnership Forum	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	Regional and State Strategic Partnership Forum Form	Regional and State Strategic Partnership Forum Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 70	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Justification - State Strategic Partnership Forum Evaluation Generic Clearance.docx Draft 1.docx	09/08/2016

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