Information Collection

HRSA Web Survey

IC 264362 under ICR 202503-0906-002 · OMB 0906-0084.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 HRSA Web Survey	Form
Form 1 English Language Survey HRSA Web Survey	Form
Form 2 Spanish Language Survey HRSA Web Survey	Form
1 English Language Survey hrsa-approved-survey-questions-final_ENG.docx	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
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
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: Unchanged

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				Yes	Yes	Fillable Fileable
Form	2				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	Previously Approved
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		01/09/2024

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

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