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

Forms and Documents

Document Name	Status
Form 1 HRSA/HIV & AIDS Bureau (HAB) Recipients Satisfaction Survey (RSS). Form and Instruction	Unchanged
Form 1 HRSA/HIV & AIDS Bureau (HAB) Recipients Satisfaction Survey (RSS). Form and Instruction	Unchanged
Form 1 Division of Practitioner Data Bank (DPDB) Webinar Feedback and Satisfaction Surveys Form	Unchanged
Form 1 Division of Practitioner Data Bank (DPDB) Webinar Feedback and Satisfaction Surveys Form	Unchanged
Form 1 BPHC Customer Service Survey Form and Instruction	Unchanged
Form 1 BPHC Customer Service Survey Form and Instruction	Unchanged
Form 2 2024 National Ryan White Conference on HIV Care & Treatment Evaluation Form	Unchanged
Form 2 2024 National Ryan White Conference on HIV Care & Treatment Evaluation Form	Unchanged
Form 1 HRSA Web Survey Form	Unchanged
Form 1 HRSA Web Survey Form	Unchanged
Form 1 MIECHV TARC Satisfaction Survey Form and Instruction	Unchanged
Form 1 MIECHV TARC Satisfaction Survey Form and Instruction	Unchanged
Form 1 Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation Form and Instruction	Unchanged
Form 1 Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation Form and Instruction	Unchanged
Form 1 Collection of Qualitative Feedback on Telehealth.HHS.gov Form	Unchanged
Form 1 Collection of Qualitative Feedback on Telehealth.HHS.gov Form	Unchanged
Form 1 HRSA Web Survey Form	Unchanged
Form 1 HRSA Web Survey Form	Unchanged
Form 1 Title V Information System User Satisfaction Survey Form and Instruction	Unchanged
Form 1 Title V Information System User Satisfaction Survey Form and Instruction	Unchanged
Form 1 Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys Form	Unchanged
Form 1 Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys Form	Unchanged
Form 1 Collection of Qualitative Feedback on Telehealth.HHS.gov Form and Instruction	Unchanged
Form 1 Collection of Qualitative Feedback on Telehealth.HHS.gov Form and Instruction	Unchanged
Form 1 National Practitioner Data Bank Usability Survey Form and Instruction	Unchanged
Form 1 National Practitioner Data Bank Usability Survey Form and Instruction	Unchanged
Form 1 Evaluation Survey of Eligible National Practitioner Data Bank Entity Users: Relevance of Information Collected via NPDB Query Forms Form and Instruction	Unchanged
Form 1 Evaluation Survey of Eligible National Practitioner Data Bank Entity Users: Relevance of Information Collected via NPDB Query Forms Form and Instruction	Unchanged
Form 1 National Marrow Donor Program Donation Experience Survey Form and Instruction	Unchanged
Form 1 National Marrow Donor Program Donation Experience Survey Form and Instruction	Unchanged
Form 1 Maternal, Infant, and Early Childhood Home Visiting Site Visit Awardee Feedback Form Form and Instruction	Unchanged
Form 1 Maternal, Infant, and Early Childhood Home Visiting Site Visit Awardee Feedback Form Form and Instruction	Unchanged
Form 1 Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form Form	Unchanged
Form 1 Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form Form	Unchanged
Form 1 2024 Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Evaluation Surveys Form	Unchanged
Form 1 2024 Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Evaluation Surveys Form	Unchanged
Form 1 Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys Form	Unchanged
Form 1 Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys Form	Unchanged
Form 1 Health Center Program Support Customer Service Survey Form and Instruction	Unchanged
Form 1 Health Center Program Support Customer Service Survey Form and Instruction	Unchanged
Form 1 HRSA Electronic Handbooks Customer Service Survey Form and Instruction	Unchanged
Form 1 HRSA Electronic Handbooks Customer Service Survey Form and Instruction	Unchanged
Form A Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys Form and Instruction	Unchanged
Form A Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys Form and Instruction	Unchanged
Form 1.1 Division of Independent Review Objective Review Assessment Survey Form and Instruction	Unchanged
Form 1.1 Division of Independent Review Objective Review Assessment Survey Form and Instruction	Unchanged
Form 1 Division of Grants Management Operations Customer Service Satisfaction Survey Form	Unchanged
Form 1 Division of Grants Management Operations Customer Service Satisfaction Survey Form	Unchanged
0906 0084_NSC Memo.docx Justification for No Material/Nonsubstantive Change	2024-06-28
0906 0084_NSC Memo.docx Justification for No Material/Nonsubstantive Change	2024-06-28
Focus Group Example_Screening Questions.docx Supplementary Document	2024-01-09
Focus Group Example_Screening Questions.docx Supplementary Document	2024-01-09
Focus Group Example_Informed Consent.docx Supplementary Document	2024-01-09
Focus Group Example_Informed Consent.docx Supplementary Document	2024-01-09
Focus Group Example_Focus Group Guide.docx Supplementary Document	2024-01-09
Focus Group Example_Focus Group Guide.docx Supplementary Document	2024-01-09
Supporting Statement B 12.8.23.docx Supporting Statement B	2024-01-09
Supporting Statement B 12.8.23.docx Supporting Statement B	2024-01-09
Supporting Statement A 12.8.23.docx Supporting Statement A	2024-01-09
Supporting Statement A 12.8.23.docx Supporting Statement A	2024-01-09

IC Document Collections

IC ID	Document Title	Status
268809	Technical Assistance to Support the HHS Viral Hepatitis National Strategic Plan Other-Interview Questions	Unchanged
267884	HRSA/HIV & AIDS Bureau (HAB) Recipients Satisfaction Survey (RSS). Form and Instruction	Unchanged
267884	HRSA/HIV & AIDS Bureau (HAB) Recipients Satisfaction Survey (RSS). Form and Instruction	Unchanged
267569	Division of Practitioner Data Bank (DPDB) Webinar Feedback and Satisfaction Surveys Form	Unchanged
267569	Division of Practitioner Data Bank (DPDB) Webinar Feedback and Satisfaction Surveys Form	Unchanged
266289	BPHC Customer Service Survey Form and Instruction	Unchanged
266289	BPHC Customer Service Survey Form and Instruction	Unchanged
266140	2024 National Ryan White Conference on HIV Care & Treatment Evaluation Form	Unchanged
266140	2024 National Ryan White Conference on HIV Care & Treatment Evaluation Form	Unchanged
266005	HRSA Web Survey Form	Unchanged
266005	HRSA Web Survey Form	Unchanged
265734	MIECHV TARC Satisfaction Survey Form and Instruction	Unchanged
265734	MIECHV TARC Satisfaction Survey Form and Instruction	Unchanged
265672	DIR Objective Review Assessment Survey Instruction	Unchanged
265627	Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation Form and Instruction	Unchanged
265627	Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation Form and Instruction	Unchanged
265626	Collection of Qualitative Feedback on Telehealth.HHS.gov Form	Unchanged
265626	Collection of Qualitative Feedback on Telehealth.HHS.gov Form	Unchanged
264362	HRSA Web Survey Form	Unchanged
264362	HRSA Web Survey Form	Unchanged
264361	Title V Information System User Satisfaction Survey Form and Instruction	Unchanged
264361	Title V Information System User Satisfaction Survey Form and Instruction	Unchanged
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys Form	Unchanged
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys Form	Unchanged
264359	Tree Testing of HRSA's Ryan White HIV/AIDS Program website Other-Tree Test Plan	Unchanged
264357	Collection of Qualitative Feedback on Telehealth.HHS.gov Form and Instruction	Unchanged
264357	Collection of Qualitative Feedback on Telehealth.HHS.gov Form and Instruction	Unchanged
264355	National Practitioner Data Bank Usability Survey Form and Instruction	Unchanged
264355	National Practitioner Data Bank Usability Survey Form and Instruction	Unchanged
264354	Evaluation Survey of Eligible National Practitioner Data Bank Entity Users: Relevance of Information Collected via NPDB Query Forms Form and Instruction	Unchanged
264354	Evaluation Survey of Eligible National Practitioner Data Bank Entity Users: Relevance of Information Collected via NPDB Query Forms Form and Instruction	Unchanged
264353	National Marrow Donor Program Donation Experience Survey Form and Instruction	Unchanged
264353	National Marrow Donor Program Donation Experience Survey Form and Instruction	Unchanged
264352	Maternal, Infant, and Early Childhood Home Visiting Site Visit Awardee Feedback Form Form and Instruction	Unchanged
264352	Maternal, Infant, and Early Childhood Home Visiting Site Visit Awardee Feedback Form Form and Instruction	Unchanged
264351	Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form Form	Unchanged
264351	Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form Form	Unchanged
264349	2024 Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Evaluation Surveys Form	Unchanged
264349	2024 Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Evaluation Surveys Form	Unchanged
264348	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys Form	Unchanged
264348	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys Form	Unchanged
264347	Health Center Program Support Customer Service Survey Form and Instruction	Unchanged
264347	Health Center Program Support Customer Service Survey Form and Instruction	Unchanged
264346	HRSA Electronic Handbooks Customer Service Survey Form and Instruction	Unchanged
264346	HRSA Electronic Handbooks Customer Service Survey Form and Instruction	Unchanged
264345	Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys Form and Instruction	Unchanged
264345	Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys Form and Instruction	Unchanged
264344	Division of Independent Review Objective Review Assessment Survey Form and Instruction	Unchanged
264344	Division of Independent Review Objective Review Assessment Survey Form and Instruction	Unchanged
264342	Division of Grants Management Operations Customer Service Satisfaction Survey Form	Unchanged
264342	Division of Grants Management Operations Customer Service Satisfaction Survey Form	Unchanged

ICR Details

OMB Control No: 0906-0084	ICR Reference No: 202406-0906-005
Status: Active	Previous ICR Reference No: 202402-0906-004
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/08/2024
	Date Received in OIRA: 06/28/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2027	02/28/2027	02/28/2027
Responses	136,977	0	98,000
Time Burden (Hours)	15,045	0	13,250
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: 27

IC Title	Form No.	Form Name
BPHC Customer Service Survey	1	Customer Feedback Survey
MIECHV TARC Satisfaction Survey	1, 2, 3, 4, 5, 6, 7, 9, 8, 10	Adaptive Leadership Academy Completion Survey ,   Community of Practice Survey Completion Survey ,   Practicum Check In Survey ,   CQI Practicum Polls ,   Individualized Targeted TA Check in ,   Small Group TA Closeout Survey ,   TARC Meeting Poll ,   Webinar Survey ,   CQI Practicum Completion Survey ,   Individualized Targeted TA
2024 Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Evaluation Surveys	1	Conference Evaluation Survey
2024 National Ryan White Conference on HIV Care & Treatment Evaluation	2, 3, 1	2024 NWRC Conference Session Questionaire ,   2024 Ryan White CEU Session Evaluation ,   Overall 2024 NRWC Conference Evaluation
Collection of Qualitative Feedback on Telehealth.HHS.gov	1, 2	Website user (page-level survey) ,   Website user (site-wide survey)
Collection of Qualitative Feedback on Telehealth.HHS.gov	1, 2	Telehealth Website - Page Level - SurveyEngSpan ,   Telehealth Website - Site Level - Survey EngSpan
DIR Objective Review Assessment Survey	2D, 2E, 2F, 3A, 3C, 3E, 3D, 3F, 3G, 3H, 1, 2, 3, 1A, 1B, 1C, 3B, 2B, 2C, 2A	Questions 1-5 ,   Reviewer Evaluation Form ,   Reviewer Evaluation Field Review ,   Chair Reviewer Evaluation Q1-2 ,   Chair Reviewer Evaluation Review Form Q3-4 ,   Chair Reviewer Evaluation Review Q5 ,   Reviewer Evaluation- Field Review Q1-2 ,   Reviewer Evaluation- Field Review Q3-4 ,   Reviewer Evaluation- Field Review Q5-6 ,   Reviewer Evaluation- Field Review Q7-8 ,   Reviewer Evaluation- Field Review Q9-10 ,   Reviewer Evaluation- Field Review Q11-12 ,   Reviewer Evaluation Q1-2 ,   Reviewer Evaluation- Field Review Q3-4 ,   Reviewer Evaluation- Field Review Q5-6 ,   Reviewer Evaluation Q9-10 ,   Reviewer Evaluation- Field Review Q7-8 ,   Reviewer Evaluation- Field Review Q11-12 ,   Reviewer Evaluation- Field Review Q13-14 ,   Reviewer Evaluation- Field Review Q15
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
Division of Practitioner Data Bank (DPDB) Webinar Feedback and Satisfaction Surveys	1	Webinar Survey Questions
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
Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation	1, 2, 3	CERV-Net 3-Month Follow-Up Test ,   CERV-Net Post-Test ,   CERV-Net Pre-Test
HRSA Electronic Handbooks Customer Service Survey	1	EHB Customer Support Center Survey Screenshot
HRSA Web Survey	1, 2	English Language Survey ,   Spanish Language Survey
HRSA Web Survey	2, 1	HRSA Web Survey ,   HRSA Web Survey (Spanish Language)
HRSA/HIV & AIDS Bureau (HAB) Recipients Satisfaction Survey (RSS).	1	HAB Recipients Satisfaction 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	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 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 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	1, A	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
Technical Assistance to Support the HHS Viral Hepatitis National Strategic Plan
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

	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	136,977	98,000	0	38,977	0	0
Annual Time Burden (Hours)	15,045	13,250	0	1,795	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 is requesting an increase in increase the number of responses and burden hours, due to an error that occurred when HRSA renewed this umbrella ICR in February. When HRSA revised this ICR in February, it updated five of its renewed information collections (ICs), resulting in the ICs having their hours deducted from the ICR twice. This error means that approximately 40% of the respondent budget and 14% of the burden hour budget are used on outdated collections. Since the ROCIS functionality does not allow HRSA to discontinue individual ICs within a larger Umbrella ICR, HRSA is requesting an increase of 38,977 respondents and 1,795 burden hours so that HRSA can use the Umbrella ICR, as HRSA had originally planned.

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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: 06/28/2024

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