Information Collection

HRSA NHSC Site Survey

IC 234775 under ICR 201805-1090-002 · OMB 1090-0007.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0007 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 039 HRSA NHSC Site Survey	Form and Instruction
039 HRSA NHSC Site Survey NHSC Site Customer Survey 2018.docx	Form and Instruction
HRSA NHSC Generic Clearance Request Form -signed-.pdf Generic Clearance Request Form (039)	IC Document
OMB Mapping HRSA NHSC Site Survey 20317 A1.xlsx OMB Mapping HRSA (039)	IC Document

IC Title:

HRSA NHSC Site Survey

Agency IC Tracking Number:

039

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	039	HRSA NHSC Site Survey	NHSC Site Customer Survey 2018.docx		Yes	Yes	Fillable Printable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Clearance Request Form (039)	HRSA NHSC Generic Clearance Request Form -signed-.pdf	01/30/2019
OMB Mapping HRSA (039)	OMB Mapping HRSA NHSC Site Survey 20317 A1.xlsx	01/30/2019

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