Title V Information System User Satisfaction 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⚠️ Notice: This information collection may be referencing outdated material.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 Title V Information System User Satisfaction Survey Form and Instruction
1 Screen Shots of Title V Information System Survey 2021 Screen Shots of Title V Information System Survey 2021.docx Form and Instruction
TVIS Customer Satisfaction - Supporting Statement 03092021.docx Original Generic IC request IC Document

Information Collection (IC) Details

IC Title:	Title V Information System User Satisfaction 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Screen Shots of Title V Information System Survey 2021	Screen Shots of Title V Information System Survey 2021.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 70	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	70	70
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Original Generic IC request	TVIS Customer Satisfaction - Supporting Statement 03092021.docx	01/09/2024

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