Information Collection

HRSA Web Survey

IC 264362 under ICR 202402-0906-004 · OMB 0906-0084.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0084 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 HRSA Web Survey	Form
1 English Language Survey hrsa-approved-survey-questions-final_ENG.docx	Form
2 Spanish Language Survey hrsa-approved-survey-questions-final_ES.docx	Form
fast-track-hrsa-web-survey-20230817 Final.docx Original Generic IC Request	IC Document

IC Title:

HRSA Web Survey

Agency IC Tracking Number:

IC Status: New

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 Language Survey	hrsa-approved-survey-questions-final_ENG.docx		Yes	Yes	Fillable Fileable
Form	2	Spanish Language 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	Program Change Due to Agency Discretion
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
Original Generic IC Request	fast-track-hrsa-web-survey-20230817 Final.docx	01/09/2024

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