Information Collection

HRSA Health Center Workforce Survey: Pilot Survey

IC 260921 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⚠️ Notice: This information collection may be referencing outdated material.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 2 HRSA Health Center Workforce Survey: Pilot Survey	Form and Instruction
Form 2 HRSA Survey Draft HRSA Health Center Workforce Survey: Pilot Survey	Form and Instruction
Form 1 Informed Consent HRSA Health Center Workforce Survey: Pilot Survey	Form
2 HRSA Survey Draft HRSA Survey Draft V6.1.docx	Form and Instruction
2 HRSA Survey Draft HRSA Survey Draft V6.1.docx	Form and Instruction
1 Informed Consent Pilot Survey Informed Consent_07192021_CLEAN.docx	Form
1 Informed Consent Pilot Survey Informed Consent_07192021_CLEAN.docx	Form
Pilot Survey Supporting Statement A 07192021_CLEAN.docx Supporting Statement A	IC Document
Pilot Survey Supporting Statement A 07192021_CLEAN.docx Supporting Statement A	IC Document
Pilot Survey Supporting Statement B 07192021_CLEAN.docx Supporting Statement B	IC Document
Pilot Survey Supporting Statement B 07192021_CLEAN.docx Supporting Statement B	IC Document
Pilot Survey Invitation Email from Health Center 07192021_CLEAN.docx Pilot Survey Invitation Email from Health Center	IC Document
Pilot Survey Invitation Email from Health Center 07192021_CLEAN.docx Pilot Survey Invitation Email from Health Center	IC Document
Pilot Survey Invitation Email from JSI 07192021.docx Pilot Survey Invitation Email from JSI	IC Document
Pilot Survey Invitation Email from JSI 07192021.docx Pilot Survey Invitation Email from JSI	IC Document
Pilot Survey Invite System Form.docx Pilot Survey Invite System Form	IC Document
Pilot Survey Invite System Form.docx Pilot Survey Invite System Form	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

HRSA Health Center Workforce Survey: 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 and Instruction	2	HRSA Survey Draft	HRSA Survey Draft V6.1.docx		Yes	Yes	Fillable Fileable
Form	1	Informed Consent	Pilot Survey Informed Consent_07192021_CLEAN.docx		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: 400

Number of Respondents for Small Entity: 400

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	400	400
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	Pilot Survey Supporting Statement A 07192021_CLEAN.docx	06/29/2023
Supporting Statement B	Pilot Survey Supporting Statement B 07192021_CLEAN.docx	06/29/2023
Pilot Survey Invitation Email from Health Center	Pilot Survey Invitation Email from Health Center 07192021_CLEAN.docx	06/29/2023
Pilot Survey Invitation Email from JSI	Pilot Survey Invitation Email from JSI 07192021.docx	06/29/2023
Pilot Survey Invite System Form	Pilot Survey Invite System Form.docx	06/29/2023

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