Information Collection

HRSA Web Survey

IC 261675 under ICR 202401-0915-001 · OMB 0915-0212.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 HRSA Web Survey	Form
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

IC Title:

HRSA Web Survey

Agency IC Tracking Number:

IC Status: Unchanged

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.