Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

Forms and Documents

Document Name	Status
Form 1 Customer Feedback Survey Form and Instruction	Unchanged
Form 1 Listening Session Questions Form and Instruction	Unchanged
Form 1 Primary Health Care Digest Newsletter Subscriber Survey Form and Instruction	Unchanged
Form 1 Tree Testing of HRSA's Ryan White HIV/AIDS Program website Form and Instruction	Unchanged
Form 1 HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach (Online Focus Groups) Form and Instruction	Unchanged
Form 1 Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center (ITAC) Satisfaction Surveys Form	Unchanged
Form 1 2022 National Ryan White Conference on HIV Care & Treatment Evaluation Form and Instruction	Unchanged
Form 1 Be The Match Donation Experience Survey Form and Instruction	Unchanged
Form 1 Federal Cervical Cancer Collaborative (FCCC) Post-Roundtable Evaluation Form and Instruction	Unchanged
Form A Early Childhood Systems Technical Assistance and Coordinating Center (ECS TACC) Customer Satisfaction Surveys Form	Unchanged
Form 1 MCH Nutrition Training Needs Assessment Form and Instruction	Unchanged
Form 1 Organdonor.gov Website Survey Form and Instruction	Unchanged
Form 1 DGMO Customer Service Satisfaction Survey Form	Unchanged
Form 1 Health Center Program Support (HCPS) Customer Service Survey Form	Unchanged
Form 1 Collection of Qualitative Feedback on Telehealth.HHS.gov Form	Unchanged
Form 1 Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program On-Site Compliance Review Awardee Feedback Form Form	Unchanged
Form 1 Title V Information System (TVIS) User Satisfaction Survey Form and Instruction	Unchanged
Form 1 Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys Form	Unchanged
Form 1 HRSA Electronic Handbooks Customer Service Survey Form and Instruction	Unchanged
0915-0212_NSC Memo FINAL.docx Justification for No Material/Nonsubstantive Change	2023-08-17
Supporting Statement - part B.docx Supporting Statement B	2021-03-08
Supporting Statement A FINAL.docx Supporting Statement A	2021-03-08
Example0212 focus.doc Supplementary Document	2018-05-07
Example Focus Group HSB.docx Supplementary Document	2018-05-07
Example Customer Survey OFAM.pdf Supplementary Document	2018-05-07
Example Customer Survey BHW.pdf Supplementary Document	2018-05-07

IC Document Collections

IC ID	Document Title	Status
260381	Customer Feedback Survey Form and Instruction	Unchanged
259969	Listening Session Questions Form and Instruction	Unchanged
259876	Primary Health Care Digest Newsletter Subscriber Survey Form and Instruction	Unchanged
259711	Tree Testing of HRSA's Ryan White HIV/AIDS Program website Form and Instruction	Unchanged
259277	Feedback and Lessons Learned from CBO Program Award Recipients Instruction	Unchanged
259013	HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach (Online Focus Groups) Form and Instruction	Unchanged
258285	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center (ITAC) Satisfaction Surveys Form	Unchanged
254660	2022 National Ryan White Conference on HIV Care & Treatment Evaluation Form and Instruction	Unchanged
253158	Health Center COVID-19 Vaccine Program (HCVP) After-Action Survey Instruction	Unchanged
252323	Be The Match Donation Experience Survey Form and Instruction	Unchanged
252068	Federal Cervical Cancer Collaborative (FCCC) Post-Roundtable Evaluation Form and Instruction	Unchanged
250631	Early Childhood Systems Technical Assistance and Coordinating Center (ECS TACC) Customer Satisfaction Surveys Form	Unchanged
250357	MCH Nutrition Training Needs Assessment Form and Instruction	Unchanged
248953	Organdonor.gov Website Survey Form and Instruction	Unchanged
248753	DGMO Customer Service Satisfaction Survey Form	Unchanged
248514	Health Center Program Support (HCPS) Customer Service Survey Form	Unchanged
248260	Collection of Qualitative Feedback on Telehealth.HHS.gov Form	Unchanged
247769	DIR Objective Review Assessment Survey Instruction	Unchanged
247472	Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program On-Site Compliance Review Awardee Feedback Form Form	Unchanged
247059	Title V Information System (TVIS) User Satisfaction Survey Form and Instruction	Unchanged
247043	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys Form	Unchanged
246973	HRSA Electronic Handbooks Customer Service Survey Form and Instruction	Unchanged

ICR Details

OMB Control No: 0915-0212	ICR Reference No: 202308-0915-005
Status: Received in OIRA	Previous ICR Reference No: 202103-0915-002
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: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/17/2023

	Requested	Previously Approved
Expiration Date	04/30/2024	04/30/2024
Responses	69,250	52,250
Time Burden (Hours)	6,725	5,375
Cost Burden (Dollars)	0	0

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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.

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

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:
	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

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

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	1, 2, 3, 4	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, 9, 10, 5	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

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ICR Summary of Burden

	Total Request	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	69,250	52,250	0	17,000	0	0
Annual Time Burden (Hours)	6,725	5,375	0	1,350	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: There has been an increase in interest in the use of fast-track generic packages within HRSA. As a result, HRSA has seen increased use of the burden hours and responses in the original ICR.As a result, HRSA is requesting an increase in 17,000 responses and 1,000 burden hours to allow HRSA to continue to use this generic umbrella ICR as necessary. HRSA is not requesting changes to the instruments currently approved at this time. We have already alerted our desk office.

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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

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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: 08/17/2023

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