HRSA Web Survey

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Document Name Document Type
Form 1 HRSA Web Survey Form
1 English Version_HRSA Web Survey hrsa-approved-survey-questions-final_ENG.docx Form
1 English Version_HRSA Web Survey hrsa-approved-survey-questions-final_ENG.docx Form
2 Spanish Version_HRSA Web Survey hrsa-approved-survey-questions-final_ES.docx Form
2 Spanish Version_HRSA Web Survey hrsa-approved-survey-questions-final_ES.docx Form
fast-track-hrsa-web-survey-20230817 Final.docx HRSA Web Survey Memo IC Document
fast-track-hrsa-web-survey-20230817 Final.docx HRSA Web Survey Memo IC Document

Information Collection (IC) Details

IC Title:	HRSA Web Survey	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	English Version_HRSA Web Survey	hrsa-approved-survey-questions-final_ENG.docx		Yes	Yes	Fillable Fileable
Form	2	Spanish Version_HRSA Web Survey	hrsa-approved-survey-questions-final_ES.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16,667	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	16,667	16,667
Annual IC Time Burden (Hours)	833	833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HRSA Web Survey Memo	fast-track-hrsa-web-survey-20230817 Final.docx	08/22/2023

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