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 1 Customer Feedback Survey	Form and Instruction	New	Repair queued
Form 1 Listening Session Questions	Form and Instruction	New	Repair queued
Form 1 Primary Health Care Digest Newsletter Subscriber Survey	Form and Instruction	New	Repair queued
Form 1 Tree Test Script	Form and Instruction	New	Repair queued
Form 1 Tree Test Plan	Form and Instruction	New	Repair queued
Form 2 Screening Questions	Form and Instruction	New	Repair queued
Form 3 Informed Consent	Form and Instruction	New	Repair queued
Form 1 Focus Group Moderators Guide	Form and Instruction	New	Repair queued
Form 3 Post Learning Collaborative Survey	Form	New	Repair queued
Form 2 Post Webinar Survey	Form	New	Repair queued
Form 1 Annual Awardee Survey	Form	New	Repair queued
Form 4 Conference (Overall) Evaluation	Form and Instruction	New	Repair queued
Form 3 CEU Breakout Session Evaluation	Form and Instruction	New	Repair queued
Form 2 Conference Breakout Session Evaluation	Form and Instruction	New	Repair queued
Form 1 Conference Plenary Session Evaluation	Form and Instruction	New	Repair queued
Form 1 BTM Donation Experience Survey - CLEAN.docx	Form and Instruction	New	Repair queued
Form 1 Post-Roundtable-Survey_V02-Final.pdf	Form and Instruction	New	Repair queued
Form D Attachment D_ECS TACC Semi-Annual Interview Protocol.docx	Form	New	Repair queued
Form C Attachment C_ECS TACC TA Resources Products Survey.docx	Form	New	Repair queued
Form B Attachment B_ECS TACC Webinar Survey.docx	Form	New	Repair queued
Form A Attachment A_ECS TACC Community of Practice Survey.docx	Form	New	Repair queued
Form 1 Survey 2022 MCH Nutrition Training Needs Assessment_10.29.21.docx	Form and Instruction	New	Repair queued
Form 1 HRSA DoT Organdonor.gov Website Survey Questionnaire.docx	Form and Instruction	New	Repair queued
Form 1 DGMO Customer Service Survey Questions.docx	Form	New	Repair queued
Form 1 HCPS - 2021 Sample Customer Service Survey--Salesforce In Sandbox.docx	Form	New	Repair queued
Form 2 Telehealth Website - Site Level - Survey EngSpan.docx	Form	New	Repair queued
Form 1 Telehealth Website - Page Level - SurveyEngSpan.docx	Form	New	Repair queued
Form 2 FORM CHAIR Q 1-5.pdf	Form and Instruction	New	Repair queued
Form 1.2 Reviewer Evaluation-Field Review Q 1 - 12.pdf	Form	New	Repair queued
Form 1 Reviewer Evaluation Q 1- 15.pdf	Form	New	Repair queued
Form 1 MIECHV On-Site Compliance Review Awardee Feedback Form_May2021.docx	Form	New	Repair queued
Form 1 Screen Shots of Title V Information System Survey 2021	Form and Instruction	New	Repair queued
Form 10 Attachment J_CQI Practicum Completion Survey	Form	New	Available
Form 9 Attachment I_CQI Practicum Check in Survey	Form	New	Available
Form 8 Attachment H_Quarterly Overall TA Survey	Form	New	Available
Form 7 Attachment G_Leadership Academy Completion Survey	Form	New	Available
Form 6 Attachment F_Leadership Academy Session Survey	Form	New	Available
Form 5 Attachment E_Community of Practice Survey	Form	New	Available
Form 4 Attachment D_Webinar Survey	Form	New	Available
Form 3 Attachment C_Project Officer Survey	Form	New	Available
Form 2 Attachment B_Individualized Targeted TA Closeout	Form	New	Available
Form 1 Attachment A_Individualized Targeted TA Check in	Form	New	Available
Form 1 EHBs Customer Support Center Survey Screenshot.docx	Form and Instruction	New	Available
Supporting Statement - part B.docx	Supporting Statement B	Uploaded 2021-03-08	Repair queued
Supporting Statement A FINAL.docx	Supporting Statement A	Uploaded 2021-03-08	Repair queued
Example0212 focus.doc	Supplementary Document	Uploaded 2018-05-07	Repair queued
Example Focus Group HSB.docx	Supplementary Document	Uploaded 2018-05-07	Repair queued
Example Customer Survey OFAM.pdf	Supplementary Document	Uploaded 2018-05-07	Repair queued
Example Customer Survey BHW.pdf	Supplementary Document	Uploaded 2018-05-07	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
260381	Customer Feedback Survey	Form and Instruction	New	Customer Feedback Survey
259969	Listening Session Questions	Form and Instruction	New	Listening Session Questions
259876	Primary Health Care Digest Newsletter Subscriber Survey	Form and Instruction	New	Primary Health Care Digest Newsletter Subscriber Survey
259711	Tree Testing of HRSA's Ryan White HIV/AIDS Program website	Form and Instruction	New	Tree Test Script
259711	Tree Testing of HRSA's Ryan White HIV/AIDS Program website	Form and Instruction	New	Tree Test Plan
259277	Feedback and Lessons Learned from CBO Program Award Recipients	Instruction	New
259013	HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach (Online Focus Groups)	Form and Instruction	New	Screening Questions
259013	HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach (Online Focus Groups)	Form and Instruction	New	Informed Consent
259013	HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach (Online Focus Groups)	Form and Instruction	New	Focus Group Moderators Guide
258285	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center (ITAC) Satisfaction Surveys	Form	New	Post Learning Collaborative Survey
258285	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center (ITAC) Satisfaction Surveys	Form	New	Post Webinar Survey
258285	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center (ITAC) Satisfaction Surveys	Form	New	Annual Awardee Survey
254660	2022 National Ryan White Conference on HIV Care & Treatment Evaluation	Form and Instruction	New	Conference (Overall) Evaluation
254660	2022 National Ryan White Conference on HIV Care & Treatment Evaluation	Form and Instruction	New	CEU Breakout Session Evaluation
254660	2022 National Ryan White Conference on HIV Care & Treatment Evaluation	Form and Instruction	New	Conference Breakout Session Evaluation
254660	2022 National Ryan White Conference on HIV Care & Treatment Evaluation	Form and Instruction	New	Conference Plenary Session Evaluation
253158	Health Center COVID-19 Vaccine Program (HCVP) After-Action Survey	Instruction	New
252323	Be The Match Donation Experience Survey	Form and Instruction	New	BTM Donation Experience Survey - CLEAN.docx
252068	Federal Cervical Cancer Collaborative (FCCC) Post-Roundtable Evaluation	Form and Instruction	New	Post-Roundtable-Survey_V02-Final.pdf
250631	Early Childhood Systems Technical Assistance and Coordinating Center (ECS TACC) Customer Satisfaction Surveys	Form	New	Attachment D_ECS TACC Semi-Annual Interview Protocol.docx
250631	Early Childhood Systems Technical Assistance and Coordinating Center (ECS TACC) Customer Satisfaction Surveys	Form	New	Attachment C_ECS TACC TA Resources Products Survey.docx
250631	Early Childhood Systems Technical Assistance and Coordinating Center (ECS TACC) Customer Satisfaction Surveys	Form	New	Attachment B_ECS TACC Webinar Survey.docx
250631	Early Childhood Systems Technical Assistance and Coordinating Center (ECS TACC) Customer Satisfaction Surveys	Form	New	Attachment A_ECS TACC Community of Practice Survey.docx
250357	MCH Nutrition Training Needs Assessment	Form and Instruction	New	Survey 2022 MCH Nutrition Training Needs Assessment_10.29.21.docx
248953	Organdonor.gov Website Survey	Form and Instruction	New	HRSA DoT Organdonor.gov Website Survey Questionnaire.docx
248753	DGMO Customer Service Satisfaction Survey	Form	New	DGMO Customer Service Survey Questions.docx
248514	Health Center Program Support (HCPS) Customer Service Survey	Form	New	HCPS - 2021 Sample Customer Service Survey--Salesforce In Sandbox.docx
248260	Collection of Qualitative Feedback on Telehealth.HHS.gov	Form	New	Telehealth Website - Site Level - Survey EngSpan.docx
248260	Collection of Qualitative Feedback on Telehealth.HHS.gov	Form	New	Telehealth Website - Page Level - SurveyEngSpan.docx
247769	DIR Objective Review Assessment Survey	Form and Instruction	New	FORM CHAIR Q 1-5.pdf
247769	DIR Objective Review Assessment Survey	Form	New	Reviewer Evaluation-Field Review Q 1 - 12.pdf
247769	DIR Objective Review Assessment Survey	Form	New	Reviewer Evaluation Q 1- 15.pdf
247769	DIR Objective Review Assessment Survey	Instruction	New
247472	Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program On-Site Compliance Review Awardee Feedback Form	Form	New	MIECHV On-Site Compliance Review Awardee Feedback Form_May2021.docx
247059	Title V Information System (TVIS) User Satisfaction Survey	Form and Instruction	New	Screen Shots of Title V Information System Survey 2021
247043	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	Form	New	Attachment J_CQI Practicum Completion Survey
247043	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	Form	New	Attachment I_CQI Practicum Check in Survey
247043	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	Form	New	Attachment H_Quarterly Overall TA Survey
247043	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	Form	New	Attachment G_Leadership Academy Completion Survey
247043	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	Form	New	Attachment F_Leadership Academy Session Survey
247043	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	Form	New	Attachment E_Community of Practice Survey
247043	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	Form	New	Attachment D_Webinar Survey
247043	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	Form	New	Attachment C_Project Officer Survey
247043	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	Form	New	Attachment B_Individualized Targeted TA Closeout
247043	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	Form	New	Attachment A_Individualized Targeted TA Check in
246973	HRSA Electronic Handbooks Customer Service Survey	Form and Instruction	New	EHBs Customer Support Center Survey Screenshot.docx

ICR Details

OMB Control No: 0915-0212	ICR Reference No: 202103-0915-002
Status: Historical Active	Previous ICR Reference No: 202012-0915-001
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: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/16/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/16/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2024	36 Months From Approved	07/31/2021
Responses	52,250	0	52,250
Time Burden (Hours)	5,375	0	5,488
Cost Burden (Dollars)	0	0	0

---

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.

---

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

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 81210	12/15/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 14462	03/16/2021
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 22

table that charts list of burden

IC Title	Form No.	Form Name
MCH Nutrition Training Needs Assessment	1	Survey 2022 MCH Nutrition Training Needs Assessment_10.29.21.docx
2022 National Ryan White Conference on HIV Care & Treatment Evaluation	4, 1, 2, 3	Conference Plenary Session Evaluation ,   Conference Breakout Session Evaluation ,   CEU Breakout Session Evaluation ,   Conference (Overall) Evaluation
Be The Match Donation Experience Survey	1	BTM Donation Experience Survey - CLEAN.docx
Collection of Qualitative Feedback on Telehealth.HHS.gov	1, 2	Telehealth Website - Page Level - SurveyEngSpan.docx ,   Telehealth Website - Site Level - Survey EngSpan.docx
Customer Feedback Survey	1	Customer Feedback Survey
DGMO Customer Service Satisfaction Survey	1	DGMO Customer Service Survey Questions.docx
DIR Objective Review Assessment Survey	1, 1.2, 2	Reviewer Evaluation Q 1- 15.pdf ,   Reviewer Evaluation-Field Review Q 1 - 12.pdf ,   FORM CHAIR Q 1-5.pdf
Early Childhood Systems Technical Assistance and Coordinating Center (ECS TACC) Customer Satisfaction Surveys	A, B, C, D	Attachment A_ECS TACC Community of Practice Survey.docx ,   Attachment B_ECS TACC Webinar Survey.docx ,   Attachment C_ECS TACC TA Resources Products Survey.docx ,   Attachment D_ECS TACC Semi-Annual Interview Protocol.docx
Federal Cervical Cancer Collaborative (FCCC) Post-Roundtable Evaluation	1	Post-Roundtable-Survey_V02-Final.pdf
Feedback and Lessons Learned from CBO Program Award Recipients
HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach (Online Focus Groups)	1, 3, 2	Focus Group Moderators Guide ,   Informed Consent ,   Screening Questions
HRSA Electronic Handbooks Customer Service Survey	1	EHBs Customer Support Center Survey Screenshot.docx
Health Center COVID-19 Vaccine Program (HCVP) After-Action Survey
Health Center Program Support (HCPS) Customer Service Survey	1	HCPS - 2021 Sample Customer Service Survey--Salesforce In Sandbox.docx
Listening Session Questions	1	Listening Session Questions
Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program On-Site Compliance Review Awardee Feedback Form	1	MIECHV On-Site Compliance Review Awardee Feedback Form_May2021.docx
Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center (ITAC) Satisfaction Surveys	2, 1, 3	Annual Awardee Survey ,   Post Webinar Survey ,   Post Learning Collaborative Survey
Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	7, 8, 1, 2, 3, 4, 6, 10, 5, 9	Attachment A_Individualized Targeted TA Check in ,   Attachment B_Individualized Targeted TA Closeout ,   Attachment C_Project Officer Survey ,   Attachment D_Webinar Survey ,   Attachment E_Community of Practice Survey ,   Attachment F_Leadership Academy Session Survey ,   Attachment G_Leadership Academy Completion Survey ,   Attachment H_Quarterly Overall TA Survey ,   Attachment I_CQI Practicum Check in Survey ,   Attachment J_CQI Practicum Completion Survey
Organdonor.gov Website Survey	1	HRSA DoT Organdonor.gov Website Survey Questionnaire.docx
Primary Health Care Digest Newsletter Subscriber Survey	1	Primary Health Care Digest Newsletter Subscriber Survey
Title V Information System (TVIS) User Satisfaction Survey	1	Screen Shots of Title V Information System Survey 2021
Tree Testing of HRSA's Ryan White HIV/AIDS Program website	1, 1	Tree Test Plan ,   Tree Test Script

---

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)	5,375	5,488	0	-113	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: As this is an extension request, the total burden hours has been restored to the original 5,375 hours.

---

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

---

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: 03/16/2021

---