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 Facilitator Guide - New Applicant Toolkit (Part 2)	Form and Instruction	New	Repair queued
Form 1 Final Report Stakeholder Contact Language	Form and Instruction	New	Repair queued
Form 4 Student Training Feedback Form	Form and Instruction	New	Repair queued
Form 3 Operations Partner Feedback Form	Form and Instruction	New	Repair queued
Form 2 Faculty Training Feedback Form	Form and Instruction	New	Repair queued
Form 1 Collaborators Feedback Form	Form and Instruction	New	Repair queued
Form 1 CEN Financial Facilitator Guide	Form and Instruction	New	Repair queued
Form 1 Opening Questions	Form and Instruction	New	Repair queued
Form 3 Medical Malpractice Payment Reports Module	Form and Instruction	New	Repair queued
Form 4 Judgment or Conviction Reports Module	Form and Instruction	New	Repair queued
Form 5 Closing Questions	Form and Instruction	New	Repair queued
Form 2 Adverse Action Reports Module	Form and Instruction	New	Repair queued
Form 1 Informed Consent	Form	New	Available
Form 2 HRSA Survey Draft	Form and Instruction	New	Available
Form 2 HRSA Health Center Workforce Survey: Pilot Survey	Form and Instruction	New	Repair queued
Form 1 Survey	Form	New	Available
Form 1 ealth Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey	Form	New	Repair queued
Form 1 Cognitive Interview Informed Consent	Form	New	Available
Form 1 HRSA Health Center Workforce Survey: Cognitive Interviews	Form	New	Repair queued
Form 1 Listening Session Consent Form	Form	New	Available
Supporting Statement A Revision_clean.docx	Supporting Statement A	Uploaded 2023-06-29	Repair queued
Supporting Statement B Revision_clean.docx	Supporting Statement B	Uploaded 2023-06-29	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
273573	Health Center Community Engagement Network (CEN) – New Applicant Toolkit Project- Group 2	Form and Instruction	New	Facilitator Guide - New Applicant Toolkit (Part 2)
271450	Primary Care and Behavioral Health Integration (PCBHI) Training Follow Up Discussion	Instruction	New
271064	National Organ Donation Expert Opinion Survey for Information Dissemination	Form and Instruction	New	Final Report Stakeholder Contact Language
271015	Health Center Community Engagement Network (CEN) – New Applicant Toolkit Project	Instruction	New
270289	Morgan State University Maternal Health Equity Coordinating Center (MSU MHECC) Feedback Forms	Form and Instruction	New	Student Training Feedback Form
270289	Morgan State University Maternal Health Equity Coordinating Center (MSU MHECC) Feedback Forms	Form and Instruction	New	Operations Partner Feedback Form
270289	Morgan State University Maternal Health Equity Coordinating Center (MSU MHECC) Feedback Forms	Form and Instruction	New	Faculty Training Feedback Form
270289	Morgan State University Maternal Health Equity Coordinating Center (MSU MHECC) Feedback Forms	Form and Instruction	New	Collaborators Feedback Form
269235	Health Center Community Engagement Network (CEN)- Financial Sustainability AG	Form and Instruction	New	CEN Financial Facilitator Guide
266022	Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	Form and Instruction	New	Opening Questions
266022	Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	Form and Instruction	New	Medical Malpractice Payment Reports Module
266022	Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	Form and Instruction	New	Judgment or Conviction Reports Module
266022	Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	Form and Instruction	New	Closing Questions
266022	Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	Form and Instruction	New	Adverse Action Reports Module
266022	Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	Instruction	New
260923	PRA Questions for CEN Groups	Instruction	New
260922	Organ Procurement and Transplantation Network (OPTN) Stakeholder Focus Groups	Instruction	New
260921	HRSA Health Center Workforce Survey: Pilot Survey	Form	New	Informed Consent
260921	HRSA Health Center Workforce Survey: Pilot Survey	Form and Instruction	New	HRSA Survey Draft
260921	HRSA Health Center Workforce Survey: Pilot Survey	Form and Instruction	New
260920	ealth Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey	Form	New	Survey
260920	ealth Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey	Form	New
260919	HRSA Health Center Workforce Survey: Cognitive Interviews	Form	New	Cognitive Interview Informed Consent
260919	HRSA Health Center Workforce Survey: Cognitive Interviews	Form	New
260918	Health Center Workforce Survey: Listening Sessions	Form	New	Listening Session Consent Form
260918	Health Center Workforce Survey: Listening Sessions	Other-Slide Deck	New
260917	Usability Testing for HRSA.gov website properties	Instruction	New
260916	Interviews with National Hypertension Control Initiative (NHCI) Group 2 Participants	Instruction	New

ICR Details

OMB Control No: 0915-0379	ICR Reference No: 202306-0915-006
Status: Active	Previous ICR Reference No: 202004-0915-007
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/15/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/29/2023
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	11/30/2026	36 Months From Approved	11/30/2023
Responses	5,575	0	5,225
Time Burden (Hours)	3,482	0	3,200
Cost Burden (Dollars)	0	0	0

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Abstract: The overarching generic clearance for Questionnaire and Data Collection Testing, Evaluation, and Research provides HRSA with the opportunity to collect feedback from members of the public for HRSA to use when developing new questions, questionnaires, and tools; pilot/pre-test instruments to be deployed by HRSA; and to identify problems in instruments currently in use. HRSA seeks to extend OMB approval of this ICR and existing ICRs that fall under it while including a slight increase in the burden estimate to account for HRSA’s implementation of Executive Order 13985, which calls on agencies to advance racial equity and support for underserved communities through identifying and addressing barriers to equal opportunity that underserved communities may face. HRSA will likely conduct additional collections to gather information from the public so that HRSA may effectively implement this Executive Order. This generic clearance is limited to data collection for the development or revision of HRSA tools and data collection instruments, as well as reports for internal decision-making and development purposes. Information collected under this generic clearance will not be used for data collection, reports, or policy documents to be released to the public. It is anticipated that data collection approved under this generic clearance will rely heavily on qualitative techniques and not the collection of numerical data. In general, these activities are not designed to yield results that meet generally accepted standards of statistical rigor but designed to obtain information to develop clearer and more effective and efficient data collection tools that will yield more accurate results and decrease public non-response. The forms submitted under this generic clearance will be voluntary, low-burden, and uncontroversial. In addition, HRSA requests to renew the following currently approved instruments under 0915-0379 along with the renewal of this generic umbrella collection: • Health Center Workforce Well-Being Survey: Listening Sessions • Health Center Workforce Well-Being Survey: Cognitive Sessions • Health Center Workforce Well-Being Survey: Pilot Testing • Health Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey • Fast Track Interviews with National Hypertension Control Initiative (NHCI) Group 2 Participants. • Usability Testing for HRSA.gov website properties (moving from 0990-0379) • Organ Procurement and Transplantation Network (OPTN) Stakeholder Focus Groups • Ryan White HIV/AIDS Program Tree Testing Plan • PRA Questions for CEN Groups

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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

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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:
	88 FR 22459	04/13/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 42083	06/29/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Evaluation Survey of Eligible National Practitioner Data Bank (NPDB) Entity Users: Relevance of Information Collected via NPDB Report Forms	5, 2, 4, 3, 1	Adverse Action Reports Module ,   Closing Questions ,   Judgment or Conviction Reports Module ,   Medical Malpractice Payment Reports Module ,   Opening Questions
HRSA Health Center Workforce Survey: Cognitive Interviews	1	Cognitive Interview Informed Consent
HRSA Health Center Workforce Survey: Pilot Survey	2, 1	HRSA Survey Draft ,   Informed Consent
Health Center Community Engagement Network (CEN) – New Applicant Toolkit Project
Health Center Community Engagement Network (CEN) – New Applicant Toolkit Project- Group 2	1	Facilitator Guide - New Applicant Toolkit (Part 2)
Health Center Community Engagement Network (CEN)- Financial Sustainability AG	1	CEN Financial Facilitator Guide
Health Center Workforce Survey: Listening Sessions	1	Listening Session Consent Form
Interviews with National Hypertension Control Initiative (NHCI) Group 2 Participants
Morgan State University Maternal Health Equity Coordinating Center (MSU MHECC) Feedback Forms	2, 1, 3, 4	Collaborators Feedback Form ,   Faculty Training Feedback Form ,   Operations Partner Feedback Form ,   Student Training Feedback Form
National Organ Donation Expert Opinion Survey for Information Dissemination	1	Final Report Stakeholder Contact Language
Organ Procurement and Transplantation Network (OPTN) Stakeholder Focus Groups
PRA Questions for CEN Groups
Primary Care and Behavioral Health Integration (PCBHI) Training Follow Up Discussion
Usability Testing for HRSA.gov website properties
ealth Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey	1	Survey

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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	5,575	5,225	0	350	0	0
Annual Time Burden (Hours)	3,482	3,200	0	282	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: HRSA seeks to include a slight increase in the burden estimate from the 2020 ICR to account for HRSA’s implementation of Executive Order 13985 calling on agencies to advance racial equity and support for underserved communities through identifying and addressing barriers to equal opportunity that underserved communities may face. HRSA will likely be conducting additional collections to gather information from the public so that HRSA may effectively implement this Executive Order. HRSA seeks to increase the number of hours under this ICR from 3,200 hours in the previously-approved ICR to 3,482 hours in this ICR. HRSA requests to renew the following currently approved instruments under 0915-0379 along with the renewal of this generic umbrella collection. We have put these instruments and the accompanying memos into the IC List. • Health Center Workforce Well-Being Survey: Listening Sessions • Health Center Workforce Well-Being Survey: Cognitive Sessions • Health Center Workforce Well-Being Survey: Pilot Testing • Health Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey • Fast Track Interviews with National Hypertension Control Initiative (NHCI) Group 2 Participants. • Usability Testing for HRSA.gov website properties (moving from 0990-0379) • Organ Procurement and Transplantation Network (OPTN) Stakeholder Focus Groups • Ryan White HIV/AIDS Program Tree Testing Plan • PRA Questions for CEN Groups

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Annual Cost to Federal Government: $2,583,874

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: 06/29/2023

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