Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration (HRSA)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 BPHC Unmoderated Usability Testing Script (Test Instrument)	Form and Instruction	New	Repair queued
Form 1 Usability Testing Script	Form and Instruction	New	Repair queued
Form 1 Survey	Form and Instruction	New	Repair queued
Form 1 HRSA Survey Draft V6.1.docx	Form and Instruction	New	Repair queued
Form 1 Cognitive Interview Informed Consent	Form and Instruction	New	Repair queued
Form 1 Listening Session Consent Form revised July 6.docx	Form	New	Available
Template for Generic Pretesting Package Supporting Statement A.docx	Supplementary Document	Uploaded 2020-08-20	Available
FINAL Supporting Statement B Extension 8-17-20.docx	Supporting Statement B	Uploaded 2020-08-17	Available
FINAL Supporting Statement A Extension 8-17-20.docx	Supporting Statement A	Uploaded 2020-08-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
260506	Community Engagement Network	Instruction	New
260134	Organ Procurement and Transplantation Network (OPTN) Stakeholder Focus Groups	Instruction	New
256698	Fast Track Interviews with National Hypertension Control Initiative (NHCI) Group 2 Participants	Instruction	New
256609	Tree Testing of HRSA's BPHC Website	Form and Instruction	New	BPHC Unmoderated Usability Testing Script (Test Instrument)
256584	HRSA Rural Health Website Tree Testing	Form and Instruction	New	Usability Testing Script
252385	Health Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey	Form and Instruction	New	Survey
248542	Health Center Workforce Well-Being Survey: Pilot Testing	Form and Instruction	New	HRSA Survey Draft V6.1.docx
246086	Health Center Workforce Well-Being Survey: Cognitive Sessions	Form and Instruction	New	Cognitive Interview Informed Consent
243215	Health Center Workforce Well-Being Survey: Listening Sessions	Other-SLIDE DECK	New
243215	Health Center Workforce Well-Being Survey: Listening Sessions	Form	New	Listening Session Consent Form revised July 6.docx

ICR Details

OMB Control No: 0915-0379	ICR Reference No: 202004-0915-007
Status: Historical Active	Previous ICR Reference No: 201704-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No: 21433
Title: Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration (HRSA)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/21/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/15/2020
Terms of Clearance: Previous terms continue: Under this generic clearance, HRSA may conduct cognitive interviews, focus groups, field tests/pilot interviews, and experimental research in laboratory and field settings, both for evaluating questionnaires and more basic research on response errors in surveys. OMB will respond with approval or comments within two weeks of receipt. OMB and HRSA will revisit the terms of this generic clearance, as appropriate.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2023	36 Months From Approved	08/31/2020
Responses	5,225	0	5,225
Time Burden (Hours)	3,200	0	3,200
Cost Burden (Dollars)	0	0	0

---

Abstract: The purpose of collections under this generic clearance is to obtain formative information from respondents to develop new questions, questionnaires and tools and to identify problems in instruments currently in use. This clearance request is limited to formative research activities emphasizing data collection, toolkit development, and estimation procedures and reports for internal decision-making and development purposes and does not extend to the collection of data for public release or policy formation. It is anticipated that these studies will rely heavily on qualitative techniques to meet their objective.

---

Authorizing Statute(s): US Code: 42 USC 299c-3(c) Sec. 934(c) Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 12307	03/02/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 28642	05/13/2020
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Community Engagement Network
Fast Track Interviews with National Hypertension Control Initiative (NHCI) Group 2 Participants
HRSA Rural Health Website Tree Testing	1	Usability Testing Script
Health Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey	1	Survey
Health Center Workforce Well-Being Survey: Cognitive Sessions	1	Cognitive Interview Informed Consent
Health Center Workforce Well-Being Survey: Listening Sessions	1	Listening Session Consent Form revised July 6.docx
Health Center Workforce Well-Being Survey: Pilot Testing	1	HRSA Survey Draft V6.1.docx
Organ Procurement and Transplantation Network (OPTN) Stakeholder Focus Groups
Tree Testing of HRSA's BPHC Website	1	BPHC Unmoderated Usability Testing Script (Test Instrument)

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	5,225	5,225	0	0	0	0
Annual Time Burden (Hours)	3,200	3,200	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $2,257,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/15/2020

---