Information Collection

ealth Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey

IC 260920 under ICR 202306-0915-006 · OMB 0915-0379.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0379 can be found here:

2026-09-23 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 ealth Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey	Form
Form 1 Survey ealth Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey	Form
1 Survey Survey V9_FINAL (2).docx	Form
1 Survey Survey V9_FINAL (2).docx	Form
FINAL Survey Supporting Statement A.docx Supporting Statement A	IC Document
FINAL Survey Supporting Statement A.docx Supporting Statement A	IC Document
Final Pilot Survey Supporting Statement B _Update TM_highlighted revisions.docx Supporting Statement B	IC Document
Final Pilot Survey Supporting Statement B _Update TM_highlighted revisions.docx Supporting Statement B	IC Document
Health Center Workforce Survey Invitation System (Pilot Survey)- Google For.pdf Health Center Workforce Survey Invitation System (Pilot Survey)- Google Form	IC Document
Health Center Workforce Survey Invitation System (Pilot Survey)- Google For.pdf Health Center Workforce Survey Invitation System (Pilot Survey)- Google Form	IC Document
Health Center Workforce Survey Invitation System (Pilot Survey) Screenshot.png Health Center Workforce Survey Invitation System (Pilot Survey) - Screenshot	IC Document
Health Center Workforce Survey Invitation System (Pilot Survey) Screenshot.png Health Center Workforce Survey Invitation System (Pilot Survey) - Screenshot	IC Document
HRSA Workforce - Pilot II _ SurveyAnalytics Survey Spanish.pdf HRSA Workforce - Pilot II _ SurveyAnalytics Survey Spanish	IC Document
HRSA Workforce - Pilot II _ SurveyAnalytics Survey Spanish.pdf HRSA Workforce - Pilot II _ SurveyAnalytics Survey Spanish	IC Document
20220316 English_Spanish HRSA Health Center Workforce Survey and Emails_cl.docx English_Spanish HRSA Health Center Workforce Survey and Emails	IC Document
20220316 English_Spanish HRSA Health Center Workforce Survey and Emails_cl.docx English_Spanish HRSA Health Center Workforce Survey and Emails	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

ealth Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A		06/29/2023
Supporting Statement B		06/29/2023
Health Center Workforce Survey Invitation System (Pilot Survey)- Google Form		06/29/2023
Health Center Workforce Survey Invitation System (Pilot Survey) - Screenshot		06/29/2023
HRSA Workforce - Pilot II _ SurveyAnalytics Survey Spanish		06/29/2023
English_Spanish HRSA Health Center Workforce Survey and Emails		06/29/2023

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

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