Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 2-3 EP attachment 6 - online discussion board evaluation protocols.docx	Form	New	Available
Form 2-2 EP attachment 5 - cognitive interview evaluation protocols.docx	Form	New	Available
Form 2-1 EP attachment 4 - focus group evaluation protocols.docx	Form	New	Available
Form 1-3 RS attachment 3 - online discussion board participant recruitment screener.docx	Form	New	Available
Form 1-2 RS attachment 2 - cognitive interview participant recruitment screener.docx	Form	New	Available
Form 1-1 RS attachment 1 - focus group participant recruitment screener.docx	Form	New	Available
Form 2 Telehealth Website - Site Level - Survey EngSpan.docx	Form	Unchanged	Available
Form 1 Telehealth Website - Page Level - SurveyEngSpan.docx	Form	Unchanged	Available
Form 1 MIECHV On-Site Compliance Review Awardee Feedback Form.docx	Form	Unchanged	Available
Form 2 FORM Survey Questions CLEAN.docx	Form and Instruction	Unchanged	Available
Form 1 FORM Focus Group CLEAN.docx	Form and Instruction	Unchanged	Available
Form 1 Survey MCH Nutrition Training Needs Assessment.docx	Form and Instruction	Unchanged	Available
Form 1 NPDB Customer Survey Questions.docx	Form	Unchanged	Available
Form 1 National Practitioner Data Bank (NPDB) Usability Surveys	Form and Instruction	Unchanged	Available
Form 1 R Old Survey Redline - Be The Match Donation Experience Generic.docx	Form and Instruction	Unchanged	Available
Form 1 New Survey - Be The Match Donation Experience Generic.docx	Form and Instruction	Unchanged	Available
Form 1 Interview Guide - OMB Outreach Evaluations CLEAN.RA.docx	Form and Instruction	Unchanged	Available
Form 4 2020 Ryan White CEU Session Evaluation Form.docx	Form and Instruction	Unchanged	Available
Form 3 2020 NWRC Plenary Evaluation Questions for App.docx	Form and Instruction	Unchanged	Available
Form 2 2020 NWRC Breakout Evaluation Questions for App.docx	Form and Instruction	Unchanged	Available
Form 1 Overall 2020 NRWC Conference Evaluation.docx	Form and Instruction	Unchanged	Available
Form 1 Example Survey in Survey Monkey - OAMP.pdf	Form	Unchanged	Available
Form C Attachment C - List of Analytic Experts Survey.docx	Form	Unchanged	Available
Form B Attachment B - Resource Guide Survey.docx	Form	Unchanged	Available
Form A Attachment A - Data Science Training Survey.docx	Form	Unchanged	Available
Form 1 Sample Customer Service Survey--Salesforce In Test.docx	Form	Unchanged	Available
Form 1 National Practitioner Data Bank (NPDB) Webcast Survey	Form	Unchanged	Available
Form 1 DGMO Customer Service Survey Questions.docx	Form	Unchanged	Available
Form 1 2019 NPDB Education Forum Feedback Survey.pdf	Form and Instruction	Unchanged	Available
Form A Attachment A-MIECHV On-Site Compliance Review Awardee Feedback Form.docx	Form	Unchanged	Available
Form 1 UDS Reporting Modernization Customer Satisfaction Survey	Form and Instruction	Unchanged	Available
Form B All Grantee Meeting Individual Session Feeback	Form	Unchanged	Available
Form A All Grantee Meeting Feedback	Form	Unchanged	Available
Form 4 Overall 2018 NRWC Evaluation_final.docx	Form and Instruction	Unchanged	Available
Form 3 Plenary Session Evaluation Questions_final.docx	Form and Instruction	Unchanged	Available
Form 2 Breakout Session Evaluation Questions_final.docx	Form and Instruction	Unchanged	Available
Form 1 Ryan White 2018 Session Evaluation 9.18.2018 FINAL2.pdf	Form and Instruction	Unchanged	Available
Form D Attachment D - HV-PMCQI Webinar Survey.docx	Form	Unchanged	Available
Form C Attachment C - HV-PMCQI Individualized TA Survey.docx	Form	Unchanged	Available
Form B Attachment B - HV-PMCQI Information Request Survey.docx	Form	Unchanged	Available
Form A Attachment A - HV-PMCQI Annual Survey.docx	Form	Unchanged	Available
Form E Attachment E-Newsletter Survey.docx	Form	Unchanged	Available
Form D Attachment D-Targeted TA Project Officer survey.docx	Form	Unchanged	Available
Form C Attachment C-Community of Practice Survey.docx	Form	Unchanged	Available
Form B Attachment B-HV-ImpACT Event Survey.docx	Form	Unchanged	Available
Form A Attachment A-Annual Satisfaction Survey.docx	Form	Unchanged	Available
Form 1 One-Year Trainee Survey form.docx	Form	Unchanged	Available
Form 1 Screen Shots of Title V Information System Survey 2018.docx	Form and Instruction	Unchanged	Available
Form 2Q2 DIR Review Assessment Survey form 2 - screenshot Chair ReviewQ2.png	Form	Unchanged	Available
Form 2Q1 DIR Review Assessment Survey form 2 - screenshot ChairQ 1.png	Form	Unchanged	Available
Form 1Q5 DIR Review Assessment Survey form 1 - screenshot ReviwerQ5.png	Form	Unchanged	Available
Form 1Q4 DIR Review Assessment Survey form 1 - screenshot ReviwerQ4.png	Form	Unchanged	Available
Form 1Q3 DIR Review Assessment Survey form 1 - screenshot Reviwer3.png	Form	Unchanged	Available
Form 1Q2 DIR Review Assessment Survey form 1 - screenshot ReviewerQ2.png	Form	Unchanged	Available
Form 1Q1 DIR Review Assessment Survey form 1 - screenshot Reviwer Q1.png	Form	Unchanged	Available
Form 1 0212 DIR OMB Survey Binder 8-1-18.pdf - SHOWS BURDEN STMNT, OMB NO AND EXP DATE	Form and Instruction	Unchanged	Available
Form 1 BF_Webinar_Survey_4_24_2018.docx	Form	Unchanged	Available
Change Memo 0212 Umbrella.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2020-12-07	Available
Example0212 focus.doc	Supplementary Document	Uploaded 2018-05-07	Available
Example Focus Group HSB.docx	Supplementary Document	Uploaded 2018-05-07	Available
Example Customer Survey OFAM.pdf	Supplementary Document	Uploaded 2018-05-07	Available
Example Customer Survey BHW.pdf	Supplementary Document	Uploaded 2018-05-07	Available
Supporting Statement - part B.docx	Supporting Statement B	Uploaded 2018-05-07	Available
Supporting Statement A FINAL 7-18.docx	Supporting Statement A	Uploaded 2018-07-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
244935	Constituent Feedback to Oral Health Education Messages and Materials	Form	New	attachment 6 - online discussion board evaluation protocols.docx
244935	Constituent Feedback to Oral Health Education Messages and Materials	Form	New	attachment 5 - cognitive interview evaluation protocols.docx
244935	Constituent Feedback to Oral Health Education Messages and Materials	Form	New	attachment 4 - focus group evaluation protocols.docx
244935	Constituent Feedback to Oral Health Education Messages and Materials	Form	New	attachment 3 - online discussion board participant recruitment screener.docx
244935	Constituent Feedback to Oral Health Education Messages and Materials	Form	New	attachment 2 - cognitive interview participant recruitment screener.docx
244935	Constituent Feedback to Oral Health Education Messages and Materials	Form	New	attachment 1 - focus group participant recruitment screener.docx
243803	Collection of Qualitative Feedback on Telehealth.HHS.gov	Form	Unchanged	Telehealth Website - Site Level - Survey EngSpan.docx
243803	Collection of Qualitative Feedback on Telehealth.HHS.gov	Form	Unchanged	Telehealth Website - Page Level - SurveyEngSpan.docx
243729	Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form	Form	Unchanged	MIECHV On-Site Compliance Review Awardee Feedback Form.docx
243367	HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach	Form and Instruction	Unchanged	FORM Survey Questions CLEAN.docx
243367	HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach	Form and Instruction	Unchanged	FORM Focus Group CLEAN.docx
243367	HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach	Other-Screener	Unchanged
242705	Maternal and Child Health Nutrition Training Needs Assessment	Form and Instruction	Unchanged	Survey MCH Nutrition Training Needs Assessment.docx
242662	National Practitioner Data Bank Call Center Customer Satisfaction Survey	Form	Unchanged	NPDB Customer Survey Questions.docx
242595	National Practitioner Data Bank (NPDB) Usability Surveys	Form and Instruction	Unchanged	National Practitioner Data Bank (NPDB) Usability Surveys
241938	Donation Experience Survey	Form and Instruction	Unchanged	Old Survey Redline - Be The Match Donation Experience Generic.docx
241938	Donation Experience Survey	Form and Instruction	Unchanged	New Survey - Be The Match Donation Experience Generic.docx
241894	Virtual Interviews with Members of the Public to Assess Customer Experience with Organ Donation PSAs	Form and Instruction	Unchanged	Interview Guide - OMB Outreach Evaluations CLEAN.RA.docx
241510	2020 National Ryan White Conference on HIV Care and Treatment	Form and Instruction	Unchanged	2020 Ryan White CEU Session Evaluation Form.docx
241510	2020 National Ryan White Conference on HIV Care and Treatment	Form and Instruction	Unchanged	2020 NWRC Plenary Evaluation Questions for App.docx
241510	2020 National Ryan White Conference on HIV Care and Treatment	Form and Instruction	Unchanged	2020 NWRC Breakout Evaluation Questions for App.docx
241510	2020 National Ryan White Conference on HIV Care and Treatment	Form and Instruction	Unchanged	Overall 2020 NRWC Conference Evaluation.docx
240443	OAMP Customer Satisfaction Survey	Form	Unchanged	Example Survey in Survey Monkey - OAMP.pdf
240006	(MIECHV MODS) Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) Developing Strategies to Facilitate Cross-Model Collaboration and Data Sharing – Customer Satisfaction Survey Forms	Form	Unchanged	Attachment C - List of Analytic Experts Survey.docx
240006	(MIECHV MODS) Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) Developing Strategies to Facilitate Cross-Model Collaboration and Data Sharing – Customer Satisfaction Survey Forms	Form	Unchanged	Attachment B - Resource Guide Survey.docx
240006	(MIECHV MODS) Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) Developing Strategies to Facilitate Cross-Model Collaboration and Data Sharing – Customer Satisfaction Survey Forms	Form	Unchanged	Attachment A - Data Science Training Survey.docx
238306	Health Center Program Support Customer Service Survey	Form	Unchanged	Sample Customer Service Survey--Salesforce In Test.docx
237840	Division of Practitioner Data Bank (DPDB) Feedback and Satisfaction Surveys	Form	Unchanged	National Practitioner Data Bank (NPDB) Webcast Survey
236621	DGMO Customer Service Satisfaction Survey	Form	Unchanged	DGMO Customer Service Survey Questions.docx
235410	HRSA Division of Practitioner Data Bank (DPDB) 2019 Education Forum Participant Survey	Form and Instruction	Unchanged	2019 NPDB Education Forum Feedback Survey.pdf
235352	Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form	Form	Unchanged	Attachment A-MIECHV On-Site Compliance Review Awardee Feedback Form.docx
234766	UDS Reporting Modernization Customer Satisfaction Survey	Form and Instruction	Unchanged	UDS Reporting Modernization Customer Satisfaction Survey
234377	Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Feedback Forms	Form	Unchanged	All Grantee Meeting Individual Session Feeback
234377	Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Feedback Forms	Form	Unchanged	All Grantee Meeting Feedback
233091	2018 National Ryan White Conference on HIV Care & Treatment Evaluation	Form and Instruction	Unchanged	Overall 2018 NRWC Evaluation_final.docx
233091	2018 National Ryan White Conference on HIV Care & Treatment Evaluation	Form and Instruction	Unchanged	Plenary Session Evaluation Questions_final.docx
233091	2018 National Ryan White Conference on HIV Care & Treatment Evaluation	Form and Instruction	Unchanged	Breakout Session Evaluation Questions_final.docx
233091	2018 National Ryan White Conference on HIV Care & Treatment Evaluation	Form and Instruction	Unchanged	Ryan White 2018 Session Evaluation 9.18.2018 FINAL2.pdf
232942	Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys	Form	Unchanged	Attachment D - HV-PMCQI Webinar Survey.docx
232942	Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys	Form	Unchanged	Attachment C - HV-PMCQI Individualized TA Survey.docx
232942	Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys	Form	Unchanged	Attachment B - HV-PMCQI Information Request Survey.docx
232942	Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys	Form	Unchanged	Attachment A - HV-PMCQI Annual Survey.docx
232937	Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Form	Unchanged	Attachment E-Newsletter Survey.docx
232937	Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Form	Unchanged	Attachment D-Targeted TA Project Officer survey.docx
232937	Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Form	Unchanged	Attachment C-Community of Practice Survey.docx
232937	Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Form	Unchanged	Attachment B-HV-ImpACT Event Survey.docx
232937	Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Form	Unchanged	Attachment A-Annual Satisfaction Survey.docx
232590	Maternal and Child Health Epidemiology Training Course One-Year Follow-up Survey	Form	Unchanged	One-Year Trainee Survey form.docx
232547	Title V Information System (TVIS) User Satisfaction Survey	Form and Instruction	Unchanged	Screen Shots of Title V Information System Survey 2018.docx
232505	DIR Objective Peer Review Assessment Survey	Form	Unchanged	DIR Review Assessment Survey form 2 - screenshot Chair ReviewQ2.png
232505	DIR Objective Peer Review Assessment Survey	Form	Unchanged	DIR Review Assessment Survey form 2 - screenshot ChairQ 1.png
232505	DIR Objective Peer Review Assessment Survey	Form	Unchanged	DIR Review Assessment Survey form 1 - screenshot ReviwerQ5.png
232505	DIR Objective Peer Review Assessment Survey	Form	Unchanged	DIR Review Assessment Survey form 1 - screenshot ReviwerQ4.png
232505	DIR Objective Peer Review Assessment Survey	Form	Unchanged	DIR Review Assessment Survey form 1 - screenshot Reviwer3.png
232505	DIR Objective Peer Review Assessment Survey	Form	Unchanged	DIR Review Assessment Survey form 1 - screenshot ReviewerQ2.png
232505	DIR Objective Peer Review Assessment Survey	Form	Unchanged	DIR Review Assessment Survey form 1 - screenshot Reviwer Q1.png
232505	DIR Objective Peer Review Assessment Survey	Instruction	Unchanged
232505	DIR Objective Peer Review Assessment Survey	Form and Instruction	Unchanged	0212 DIR OMB Survey Binder 8-1-18.pdf - SHOWS BURDEN STMNT, OMB NO AND EXP DATE
232123	Building Futures: Supporting Youth Living with HIV, Feedback on Toolkit and Webinars	Form	Unchanged	BF_Webinar_Survey_4_24_2018.docx

ICR Details

OMB Control No: 0915-0212	ICR Reference No: 202012-0915-001
Status: Historical Active	Previous ICR Reference No: 201506-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/14/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/08/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2021	07/31/2021	07/31/2021
Responses	52,250	0	52,250
Time Burden (Hours)	5,488	0	5,375
Cost Burden (Dollars)	0	0	0

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Abstract: This generic project clearance allows HRSA to conduct voluntary customer satisfaction surveys of its partners to assess strengths and weaknesses in program services and products. Examples of such surveys include satisfaction with technical assistance provided to grantees, in class evaluations of training sessions, and satisfaction with information services.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 52308	11/13/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 18574	04/27/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 26

table that charts list of burden

IC Title	Form No.	Form Name
(MIECHV MODS) Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) Developing Strategies to Facilitate Cross-Model Collaboration and Data Sharing – Customer Satisfaction Survey Forms	C, A, B	Attachment A - Data Science Training Survey.docx ,   Attachment B - Resource Guide Survey.docx ,   Attachment C - List of Analytic Experts Survey.docx
2018 National Ryan White Conference on HIV Care & Treatment Evaluation	1, 3, 2, 4	Ryan White 2018 Session Evaluation 9.18.2018 FINAL2.pdf ,   Breakout Session Evaluation Questions_final.docx ,   Plenary Session Evaluation Questions_final.docx ,   Overall 2018 NRWC Evaluation_final.docx
2020 National Ryan White Conference on HIV Care and Treatment	1, 3, 2, 4	Overall 2020 NRWC Conference Evaluation.docx ,   2020 NWRC Breakout Evaluation Questions for App.docx ,   2020 NWRC Plenary Evaluation Questions for App.docx ,   2020 Ryan White CEU Session Evaluation Form.docx
Building Futures: Supporting Youth Living with HIV, Feedback on Toolkit and Webinars	1	BF_Webinar_Survey_4_24_2018.docx
Collection of Qualitative Feedback on Telehealth.HHS.gov	1, 2	Telehealth Website - Page Level - SurveyEngSpan.docx ,   Telehealth Website - Site Level - Survey EngSpan.docx
Constituent Feedback to Oral Health Education Messages and Materials	1-1 RS, 1-2 RS, 1-3 RS, 2-1 EP, 2-2 EP, 2-3 EP	attachment 1 - focus group participant recruitment screener.docx ,   attachment 2 - cognitive interview participant recruitment screener.docx ,   attachment 3 - online discussion board participant recruitment screener.docx ,   attachment 4 - focus group evaluation protocols.docx ,   attachment 5 - cognitive interview evaluation protocols.docx ,   attachment 6 - online discussion board evaluation protocols.docx
DGMO Customer Service Satisfaction Survey	1	DGMO Customer Service Survey Questions.docx
DIR Objective Peer Review Assessment Survey	1Q5, 1Q4, 1Q3, 1, 2Q1, 1Q2, 1Q1, 2Q2	0212 DIR OMB Survey Binder 8-1-18.pdf - SHOWS BURDEN STMNT, OMB NO AND EXP DATE ,   DIR Review Assessment Survey form 1 - screenshot Reviwer Q1.png ,   DIR Review Assessment Survey form 1 - screenshot ReviewerQ2.png ,   DIR Review Assessment Survey form 1 - screenshot Reviwer3.png ,   DIR Review Assessment Survey form 1 - screenshot ReviwerQ4.png ,   DIR Review Assessment Survey form 1 - screenshot ReviwerQ5.png ,   DIR Review Assessment Survey form 2 - screenshot ChairQ 1.png ,   DIR Review Assessment Survey form 2 - screenshot Chair ReviewQ2.png
Division of Practitioner Data Bank (DPDB) Feedback and Satisfaction Surveys	1	National Practitioner Data Bank (NPDB) Webcast Survey
Donation Experience Survey	1 R, 1	New Survey - Be The Match Donation Experience Generic.docx ,   Old Survey Redline - Be The Match Donation Experience Generic.docx
HRSA Division of Practitioner Data Bank (DPDB) 2019 Education Forum Participant Survey	1	2019 NPDB Education Forum Feedback Survey.pdf
HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach	1, 2	FORM Focus Group CLEAN.docx ,   FORM Survey Questions CLEAN.docx
Health Center Program Support Customer Service Survey	1	Sample Customer Service Survey--Salesforce In Test.docx
Maternal and Child Health Epidemiology Training Course One-Year Follow-up Survey	1	One-Year Trainee Survey form.docx
Maternal and Child Health Nutrition Training Needs Assessment	1	Survey MCH Nutrition Training Needs Assessment.docx
Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form	1	MIECHV On-Site Compliance Review Awardee Feedback Form.docx
Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form	A	Attachment A-MIECHV On-Site Compliance Review Awardee Feedback Form.docx
Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Feedback Forms	A, B	All Grantee Meeting Feedback ,   All Grantee Meeting Individual Session Feeback
Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	C, E, A, B, D	Attachment A-Annual Satisfaction Survey.docx ,   Attachment B-HV-ImpACT Event Survey.docx ,   Attachment C-Community of Practice Survey.docx ,   Attachment D-Targeted TA Project Officer survey.docx ,   Attachment E-Newsletter Survey.docx
Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys	A, B, C, D	Attachment A - HV-PMCQI Annual Survey.docx ,   Attachment B - HV-PMCQI Information Request Survey.docx ,   Attachment C - HV-PMCQI Individualized TA Survey.docx ,   Attachment D - HV-PMCQI Webinar Survey.docx
National Practitioner Data Bank (NPDB) Usability Surveys	1	National Practitioner Data Bank (NPDB) Usability Surveys
National Practitioner Data Bank Call Center Customer Satisfaction Survey	1	NPDB Customer Survey Questions.docx
OAMP Customer Satisfaction Survey	1	Example Survey in Survey Monkey - OAMP.pdf
Title V Information System (TVIS) User Satisfaction Survey	1	Screen Shots of Title V Information System Survey 2018.docx
UDS Reporting Modernization Customer Satisfaction Survey	1	UDS Reporting Modernization Customer Satisfaction Survey
Virtual Interviews with Members of the Public to Assess Customer Experience with Organ Donation PSAs	1	Interview Guide - OMB Outreach Evaluations CLEAN.RA.docx

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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	52,250	52,250	0	0	0	0
Annual Time Burden (Hours)	5,488	5,375	0	113	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: A change memo has been added to supplementary section requesting an additional 113 hours to accommodate a final generic child under this umbrella. The 113 hours has been added to the Total Time Burden.

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Annual Cost to Federal Government: $700,000

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

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Common Form ICR:  No

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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: 12/08/2020

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