Appendix D1. HSA Survey

Evaluation of Learning Health Systems K12 Training Program

Documents and Forms

Document Name Document Type
Form D1 Appendix D1. HSA Survey Form
D1 Appendix D1. HSA Survey Appendix D1. HSA Survey_5-18-20.docx Form
Appendix D2. Survey Invitation Email 5-8-20.docx Appendix D2. HSA Survey Invitation Email IC Document
Appendix D3. Survey Reminder Email 5-8-20.docx Appendix D3. HSA Survey Reminder Email IC Document
Appendix D4. Survey Reminder Telephone Script.docx Appendix D4. HSA Survey Reminder Telephone Script IC Document
Appendix D5. Survey Thank You Email 5-18-20.docx Appendix D5. HSA Survey Thank-You Email IC Document
Appendix D6. HSA Survey Screenshots.docx Appendix D6. HSA Survey Screenshots IC Document

Information Collection (IC) Details

IC Title:	Appendix D1. HSA Survey	Agency IC Tracking Number:

Is this a Common Form? No		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	D1	Appendix D1. HSA Survey	Appendix D1. HSA Survey_5-18-20.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 63	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: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	63	63
Annual IC Time Burden (Hours)	11	11
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix D2. HSA Survey Invitation Email	Appendix D2. Survey Invitation Email 5-8-20.docx	06/05/2020
Appendix D3. HSA Survey Reminder Email	Appendix D3. Survey Reminder Email 5-8-20.docx	06/05/2020
Appendix D4. HSA Survey Reminder Telephone Script	Appendix D4. Survey Reminder Telephone Script.docx	06/05/2020
Appendix D5. HSA Survey Thank-You Email	Appendix D5. Survey Thank You Email 5-18-20.docx	06/05/2020
Appendix D6. HSA Survey Screenshots	Appendix D6. HSA Survey Screenshots.docx	06/05/2020

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