Division of Independent Review Objective Review Assessment 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⚠️ Notice: This information collection may be referencing outdated material.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 0906-0084 can be found here:

Documents and Forms

Document Name Document Type
Form 1.1 Division of Independent Review Objective Review Assessment Survey Form and Instruction
Public Burden Statement Screenshot.pdf Other-Public Burden Statement Screen
1.1 Screenshot Reviewer Instr DIR Review Assessment Survey form 1 - screenshot Reviewer instr.pdf Form and Instruction
2 Form Chair Q 1-5 FORM CHAIR Q 1-5.pdf Form
1 FORM Reviewer Evaluation Q 1- 15 FORM Reviewer Evaluation Q 1- 15.pdf Form
1.2 FORM Reviewer Evaluation-Field Review Q 1 - 12 FORM Reviewer Evaluation-Field Review Q 1 - 12.pdf Form and Instruction
Supporting Statement A - DIR Review Assessment Surve.docx Original Generic Request IC Document

Information Collection (IC) Details

IC Title:	Division of Independent Review Objective Review Assessment Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1.1	Screenshot Reviewer Instr	DIR Review Assessment Survey form 1 - screenshot Reviewer instr.pdf	Yes	Yes	Fillable Fileable
Form	2	Form Chair Q 1-5	FORM CHAIR Q 1-5.pdf	Yes	Yes	Fillable Fileable
Form	1	FORM Reviewer Evaluation Q 1- 15	FORM Reviewer Evaluation Q 1- 15.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1.2	FORM Reviewer Evaluation-Field Review Q 1 - 12	FORM Reviewer Evaluation-Field Review Q 1 - 12.pdf	Yes	Yes	Fillable Fileable
Other-Public Burden Statement Screenshot			Public Burden Statement Screenshot.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,300	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,300	2,300
Annual IC Time Burden (Hours)	575	575
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Original Generic Request	Supporting Statement A - DIR Review Assessment Surve.docx	01/09/2024

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