Community Outreach Worker Profile Form

The HRSA Community Based Outreach Reporting Module

OMB: 0906-0064

IC ID: 248288

Information Collection (IC) Details

View Information Collection (IC)

Community Outreach Worker Profile Form
 
No New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 Community Outreach Worker Profile Form Community Based Vaccine Outreach Program Reporting Module 07-07-2021.docx https://www.surveymonkey.com/r/6BTQJC8 Yes Yes Fillable Fileable

Health Health Care Services

 

3,000 131
   
Private Sector Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,000 0 3,000 0 0 0
Annual IC Time Burden (Hours) 800 0 800 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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