Discussions on 50+ Donors

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⚠️ Notice: This information collection may be referencing outdated material.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 2 Discussions on 50+ Donors Form and Instruction
2 20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx Form and Instruction
3 20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx Form and Instruction
5 20170303 Attachment 5__FocusGroup_ParticipantScreener (E 20170303 Attachment 5__FocusGroup_ParticipantScreener (EP_DoT) CLEAN.docx Form and Instruction
6 20170303 Attachment 6__Survey _Screener Questionnaire - 20170303 Attachment 6__Survey _Screener Questionnaire - Rd 2 CLEAN Rd 2.docx Form and Instruction
20170303 Attachment 1__SupportingStatement_50+ (EP) RA edit.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Discussions on 50+ Donors	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx	20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx	No		Paper Only
Form and Instruction	3	20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx	20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx	No		Paper Only
Form and Instruction	5	20170303 Attachment 5__FocusGroup_ParticipantScreener (EP_DoT) CLEAN.docx	20170303 Attachment 5__FocusGroup_ParticipantScreener (EP_DoT) CLEAN.docx	No		Paper Only
Form and Instruction	6	20170303 Attachment 6__Survey _Screener Questionnaire - Rd 2 CLEAN Rd 2.docx	20170303 Attachment 6__Survey _Screener Questionnaire - Rd 2 CLEAN Rd 2.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 124	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	124	124
Annual IC Time Burden (Hours)	71	71
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	20170303 Attachment 1__SupportingStatement_50+ (EP) RA edit.docx	04/20/2017

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