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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 2 Spanish Language Survey	Form	New	Available
Form 1 English Language Survey	Form	New	Available
Form 1 HRSA Web Survey	Form	New	Repair queued
Form 1 Screen Shots of Title V Information System Survey 2021	Form and Instruction	New	Available
Form 1 Title V Information System User Satisfaction Survey	Form and Instruction	New	Repair queued
Form 10 CQI Practicum Completion Survey	Form	New	Available
Form 9 Attachment I_CQI Practicum Check in Survey	Form	New	Available
Form 8 Attachment H_Quarterly Overall TA Survey	Form	New	Available
Form 7 Attachment G_Leadership Academy Completion Survey	Form	New	Available
Form 6 Attachment F_Leadership Academy Session Survey	Form	New	Available
Form 5 Attachment E_Community of Practice Survey	Form	New	Available
Form 4 Attachment D_Webinar Survey	Form	New	Available
Form 3 Attachment C_Project Officer Survey	Form	New	Available
Form 2 Attachment B_Individualized Targeted TA Closeout	Form	New	Available
Form 1 Attachment A_Individualized Targeted TA Check in	Form	New	Available
Form 1 Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Repair queued
Form 1 Tree Test Script	Form	New	Available
Form 2 Telehealth Website - Site Level - Survey EngSpan	Form and Instruction	New	Available
Form 1 Telehealth Website - Page Level - SurveyEngSpan	Form and Instruction	New	Available
Form 1 Collection of Qualitative Feedback on Telehealth.HHS.gov	Form and Instruction	New	Repair queued
Form 1 0915-0212_UsabiltyTesting Instrument_NPDBSystem	Form and Instruction	New	Available
Form 1 National Practitioner Data Bank Usability Survey	Form and Instruction	New	Repair queued
Form 2 User Survey Questions - Query	Form and Instruction	New	Available
Form 1 Query Survey Intro-Instructions	Form and Instruction	New	Available
Form 1 Evaluation Survey of Eligible National Practitioner Data Bank Entity Users: Relevance of Information Collected via NPDB Query Forms	Form and Instruction	New	Repair queued
Form 1 Donation Experience Survey	Form and Instruction	New	Available
Form 1 National Marrow Donor Program Donation Experience Survey	Form and Instruction	New	Repair queued
Form A Instrument A MIECHV Site Visit Compliance Review Awardee Feedback Form	Form and Instruction	New	Available
Form 1 Instrument A MIECHV Site Visit Compliance Review Awardee Feedback Form Boilerplate	Form and Instruction	New	Available
Form 1 Maternal, Infant, and Early Childhood Home Visiting Site Visit Awardee Feedback Form	Form and Instruction	New	Repair queued
Form 1 On Site Compliance Review Awardee Feedback Form	Form	New	Available
Form 1 Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form	Form	New	Repair queued
Form 1 Conference Evaluation Survey	Form	New	Available
Form 1 2024 Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Evaluation Surveys	Form	New	Repair queued
Form 3 Post Learning Collaborative Survey	Form and Instruction	New	Available
Form 2 Instrument B_Post Webinar Survey	Form	New	Available
Form 1 Annual Awardee Survey	Form	New	Available
Form 1 Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Repair queued
Form 1 EHBs Customer Support Center Survey Screenshot	Form and Instruction	New	Available
Form 1 Health Center Program Support Customer Service Survey	Form and Instruction	New	Repair queued
Form 1 EHB Customer Support Center Survey Screenshot	Form and Instruction	New	Available
Form 1 HRSA Electronic Handbooks Customer Service Survey	Form and Instruction	New	Repair queued
Form Attachment D Attachment D_ECS TACC Semi-Annual Interview Protocol	Form and Instruction	New	Available
Form C Attachment C_ECS TACC TA Resources Products Survey	Form and Instruction	New	Available
Form B Attachment B_ECS TACC Webinar Survey	Form and Instruction	New	Available
Form A Attachment A_ECS TACC Community of Practice Surve	Form and Instruction	New	Available
Form A Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys	Form and Instruction	New	Repair queued
Form 1.2 FORM Reviewer Evaluation-Field Review Q 1 - 12	Form and Instruction	New	Available
Form 1 FORM Reviewer Evaluation Q 1- 15	Form	New	Available
Form 2 Form Chair Q 1-5	Form	New	Available
Form 1.1 Screenshot Reviewer Instr	Form and Instruction	New	Available
Form 1.1 Division of Independent Review Objective Review Assessment Survey	Form and Instruction	New	Repair queued
Form 1 DGMO Customer Service Survey Questions	Form	New	Available
Form 1 Division of Grants Management Operations Customer Service Satisfaction Survey	Form	New	Repair queued
Focus Group Example_Screening Questions.docx	Supplementary Document	Uploaded 2024-01-09	Repair queued
Focus Group Example_Informed Consent.docx	Supplementary Document	Uploaded 2024-01-09	Repair queued
Focus Group Example_Focus Group Guide.docx	Supplementary Document	Uploaded 2024-01-09	Repair queued
Supporting Statement B 12.8.23.docx	Supporting Statement B	Uploaded 2024-01-09	Repair queued
Supporting Statement A 12.8.23.docx	Supporting Statement A	Uploaded 2024-01-09	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
264362	HRSA Web Survey	Form	New	Spanish Language Survey
264362	HRSA Web Survey	Form	New	English Language Survey
264362	HRSA Web Survey	Form	New
264361	Title V Information System User Satisfaction Survey	Form and Instruction	New	Screen Shots of Title V Information System Survey 2021
264361	Title V Information System User Satisfaction Survey	Form and Instruction	New
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	CQI Practicum Completion Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Attachment I_CQI Practicum Check in Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Attachment H_Quarterly Overall TA Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Attachment G_Leadership Academy Completion Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Attachment F_Leadership Academy Session Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Attachment E_Community of Practice Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Attachment D_Webinar Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Attachment C_Project Officer Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Attachment B_Individualized Targeted TA Closeout
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Attachment A_Individualized Targeted TA Check in
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New
264359	Tree Testing of HRSA's Ryan White HIV/AIDS Program website	Form	New	Tree Test Script
264359	Tree Testing of HRSA's Ryan White HIV/AIDS Program website	Other-Tree Test Plan	New
264357	Collection of Qualitative Feedback on Telehealth.HHS.gov	Form and Instruction	New	Telehealth Website - Site Level - Survey EngSpan
264357	Collection of Qualitative Feedback on Telehealth.HHS.gov	Form and Instruction	New	Telehealth Website - Page Level - SurveyEngSpan
264357	Collection of Qualitative Feedback on Telehealth.HHS.gov	Form and Instruction	New
264355	National Practitioner Data Bank Usability Survey	Form and Instruction	New	0915-0212_UsabiltyTesting Instrument_NPDBSystem
264355	National Practitioner Data Bank Usability Survey	Form and Instruction	New
264354	Evaluation Survey of Eligible National Practitioner Data Bank Entity Users: Relevance of Information Collected via NPDB Query Forms	Form and Instruction	New	User Survey Questions - Query
264354	Evaluation Survey of Eligible National Practitioner Data Bank Entity Users: Relevance of Information Collected via NPDB Query Forms	Form and Instruction	New	Query Survey Intro-Instructions
264354	Evaluation Survey of Eligible National Practitioner Data Bank Entity Users: Relevance of Information Collected via NPDB Query Forms	Form and Instruction	New
264353	National Marrow Donor Program Donation Experience Survey	Form and Instruction	New	Donation Experience Survey
264353	National Marrow Donor Program Donation Experience Survey	Form and Instruction	New
264352	Maternal, Infant, and Early Childhood Home Visiting Site Visit Awardee Feedback Form	Form and Instruction	New	Instrument A MIECHV Site Visit Compliance Review Awardee Feedback Form
264352	Maternal, Infant, and Early Childhood Home Visiting Site Visit Awardee Feedback Form	Form and Instruction	New	Instrument A MIECHV Site Visit Compliance Review Awardee Feedback Form Boilerplate
264352	Maternal, Infant, and Early Childhood Home Visiting Site Visit Awardee Feedback Form	Form and Instruction	New
264351	Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form	Form	New	On Site Compliance Review Awardee Feedback Form
264351	Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form	Form	New
264349	2024 Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Evaluation Surveys	Form	New	Conference Evaluation Survey
264349	2024 Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Evaluation Surveys	Form	New
264348	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form and Instruction	New	Post Learning Collaborative Survey
264348	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Instrument B_Post Webinar Survey
264348	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New	Annual Awardee Survey
264348	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	New
264347	Health Center Program Support Customer Service Survey	Form and Instruction	New	EHBs Customer Support Center Survey Screenshot
264347	Health Center Program Support Customer Service Survey	Form and Instruction	New
264346	HRSA Electronic Handbooks Customer Service Survey	Form and Instruction	New	EHB Customer Support Center Survey Screenshot
264346	HRSA Electronic Handbooks Customer Service Survey	Form and Instruction	New
264345	Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys	Form and Instruction	New	Attachment D_ECS TACC Semi-Annual Interview Protocol
264345	Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys	Form and Instruction	New	Attachment C_ECS TACC TA Resources Products Survey
264345	Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys	Form and Instruction	New	Attachment B_ECS TACC Webinar Survey
264345	Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys	Form and Instruction	New	Attachment A_ECS TACC Community of Practice Surve
264345	Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys	Form and Instruction	New
264344	Division of Independent Review Objective Review Assessment Survey	Form and Instruction	New	FORM Reviewer Evaluation-Field Review Q 1 - 12
264344	Division of Independent Review Objective Review Assessment Survey	Form	New	FORM Reviewer Evaluation Q 1- 15
264344	Division of Independent Review Objective Review Assessment Survey	Form	New	Form Chair Q 1-5
264344	Division of Independent Review Objective Review Assessment Survey	Form and Instruction	New	Screenshot Reviewer Instr
264344	Division of Independent Review Objective Review Assessment Survey	Form and Instruction	New
264344	Division of Independent Review Objective Review Assessment Survey	Other-Public Burden Statement Screenshot	New
264342	Division of Grants Management Operations Customer Service Satisfaction Survey	Form	New	DGMO Customer Service Survey Questions
264342	Division of Grants Management Operations Customer Service Satisfaction Survey	Form	New

ICR Details

OMB Control No: 0915-0212	ICR Reference No: 202401-0915-004
Status: Historical Active	Previous ICR Reference No: 202401-0915-001
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/22/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/10/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2027	36 Months From Approved	04/30/2024
Responses	98,000	0	69,250
Time Burden (Hours)	13,250	0	6,725
Cost Burden (Dollars)	0	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:
	88 FR 72494	10/20/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 788	01/05/2024
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 17

table that charts list of burden

IC Title	Form No.	Form Name
2024 Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Evaluation Surveys	1	Conference Evaluation Survey
Collection of Qualitative Feedback on Telehealth.HHS.gov	1, 2	Telehealth Website - Page Level - SurveyEngSpan ,   Telehealth Website - Site Level - Survey EngSpan
Division of Grants Management Operations Customer Service Satisfaction Survey	1	DGMO Customer Service Survey Questions
Division of Independent Review Objective Review Assessment Survey	1.1, 2, 1, 1.2	Screenshot Reviewer Instr ,   Form Chair Q 1-5 ,   FORM Reviewer Evaluation Q 1- 15 ,   FORM Reviewer Evaluation-Field Review Q 1 - 12
Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys	A, B, C, Attachment D	Attachment A_ECS TACC Community of Practice Surve ,   Attachment B_ECS TACC Webinar Survey ,   Attachment C_ECS TACC TA Resources Products Survey ,   Attachment D_ECS TACC Semi-Annual Interview Protocol
Evaluation Survey of Eligible National Practitioner Data Bank Entity Users: Relevance of Information Collected via NPDB Query Forms	1, 2	Query Survey Intro-Instructions ,   User Survey Questions - Query
HRSA Electronic Handbooks Customer Service Survey	1	EHB Customer Support Center Survey Screenshot
HRSA Web Survey	1, 2	English Language Survey ,   Spanish Language Survey
Health Center Program Support Customer Service Survey	1	EHBs Customer Support Center Survey Screenshot
Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	2, 1, 3	Annual Awardee Survey ,   Instrument B_Post Webinar Survey ,   Post Learning Collaborative Survey
Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	1, 2, 3, 4, 5, 6, 7, 8, 9, 10	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 ,   CQI Practicum Completion Survey
Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form	1	On Site Compliance Review Awardee Feedback Form
Maternal, Infant, and Early Childhood Home Visiting Site Visit Awardee Feedback Form	A, 1	Instrument A MIECHV Site Visit Compliance Review Awardee Feedback Form Boilerplate ,   Instrument A MIECHV Site Visit Compliance Review Awardee Feedback Form
National Marrow Donor Program Donation Experience Survey	1	Donation Experience Survey
National Practitioner Data Bank Usability Survey	1	0915-0212_UsabiltyTesting Instrument_NPDBSystem
Title V Information System 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	Tree Test Script

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	98,000	69,250	0	28,750	0	0
Annual Time Burden (Hours)	13,250	6,725	0	6,525	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: HRSA anticipates that the total burden of collections under this generic package will be 6,525 hours greater than under the prior approval for two reasons. First, HRSA is incorporating the additional burden amount approved for this ICR via a 2023 non-substantive change memo. Second, HRSA is accounting for upcoming efforts to get public input from a larger swath of HRSA’s partners in compliance with Executive Order 14058. HRSA has decreased its estimate of the average burden per response for surveys to account for the increasing use of telephone and online surveys, rather than mail-in surveys, since the latter are more time-consuming.

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Annual Cost to Federal Government: $249,390

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: 01/10/2024

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