Health Center Program Support Customer Service Survey

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⚠️ Notice: This information collection may be referencing outdated material.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 Health Center Program Support Customer Service Survey Form
1 Sample Customer Service Survey--Salesforce In Test.docx Sample Customer Service Survey--Salesforce In Test.docx Form
GENERIC - Supporting Statement_BPHC Customer Service Survey-HCPS 2019_Clean_10232019.docx Generic Supporting Statement - BPHC Customer Service Srvy IC Document

Information Collection (IC) Details

IC Title:	Health Center Program Support Customer Service Survey	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	1	Sample Customer Service Survey--Salesforce In Test.docx	Sample Customer Service Survey--Salesforce In Test.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 201	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	201	201
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Generic Supporting Statement - BPHC Customer Service Srvy	GENERIC - Supporting Statement_BPHC Customer Service Survey-HCPS 2019_Clean_10232019.docx	10/29/2019

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