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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 FTCA Site Visit Follow-Up Survey	Form	New	Available
Form 1 FTCA Office Hours Participant Feedback Survey	Form	Modified	Available
Form 1 HRSA OPTN Helpline Customer Satisfaction Survey	Form	Modified	Available
Form 1 Follow up: ASPR/ Strategic National Stockpile (SNS) Dissemination and HRSA-Supported Health Centers use of JYNNEOS vaccine.	Form	Modified	Available
Form 3 Qualitative Interview	Form and Instruction	Modified	Available
Form 2 Post-TA Activity Survey	Form and Instruction	Modified	Available
Form 1 Comprehensive Survey	Form and Instruction	Modified	Available
Form 1 HAB Recipients Satisfaction Survey	Form and Instruction	Modified	Available
Form 1 Webinar Survey Questions	Form	Modified	Available
Form 1 Customer Feedback Survey	Form and Instruction	Modified	Available
Form 1 Overall 2024 NRWC Conference Evaluation	Form and Instruction	Modified	Available
Form 3 2024 Ryan White CEU Session Evaluation	Form	Modified	Available
Form 2 2024 NWRC Conference Session Questionaire	Form	Modified	Available
Form 2 HRSA Web Survey (Spanish Language)	Form	Modified	Available
Form 1 HRSA Web Survey	Form	Modified	Available
Form 10 Individualized Targeted TA	Form and Instruction	Modified	Available
Form 8 CQI Practicum Completion Survey	Form and Instruction	Modified	Available
Form 9 Webinar Survey	Form and Instruction	Modified	Available
Form 7 TARC Meeting Poll	Form and Instruction	Modified	Available
Form 6 Small Group TA Closeout Survey	Form and Instruction	Modified	Available
Form 5 Individualized Targeted TA Check in	Form and Instruction	Modified	Available
Form 4 CQI Practicum Polls	Form and Instruction	Modified	Available
Form 3 Practicum Check In Survey	Form and Instruction	Modified	Available
Form 2 Community of Practice Survey Completion Survey	Form and Instruction	Modified	Available
Form 1 Adaptive Leadership Academy Completion Survey	Form and Instruction	Modified	Available
Form 3H Reviewer Evaluation- Field Review Q15	Form and Instruction	Modified	Available
Form 3G Reviewer Evaluation- Field Review Q13-14	Form and Instruction	Modified	Available
Form 3F Reviewer Evaluation- Field Review Q11-12	Form and Instruction	Modified	Available
Form 3D Reviewer Evaluation- Field Review Q7-8	Form and Instruction	Modified	Available
Form 3E Reviewer Evaluation Q9-10	Form and Instruction	Modified	Available
Form 3C Reviewer Evaluation- Field Review Q5-6	Form and Instruction	Modified	Available
Form 3B Reviewer Evaluation- Field Review Q3-4	Form and Instruction	Modified	Available
Form 3A Reviewer Evaluation Q1-2	Form and Instruction	Modified	Available
Form 2F Reviewer Evaluation- Field Review Q11-12	Form and Instruction	Modified	Available
Form 2E Reviewer Evaluation- Field Review Q9-10	Form and Instruction	Modified	Available
Form 2D Reviewer Evaluation- Field Review Q7-8	Form and Instruction	Modified	Available
Form 2C Reviewer Evaluation- Field Review Q5-6	Form and Instruction	Modified	Available
Form 2B Reviewer Evaluation- Field Review Q3-4	Form and Instruction	Modified	Available
Form 2A Reviewer Evaluation- Field Review Q1-2	Form and Instruction	Modified	Available
Form 1C Chair Reviewer Evaluation Review Q5	Form and Instruction	Modified	Available
Form 1B Chair Reviewer Evaluation Review Form Q3-4	Form and Instruction	Modified	Available
Form 1A Chair Reviewer Evaluation Q1-2	Form and Instruction	Modified	Available
Form 3 Reviewer Evaluation Field Review	Form and Instruction	Modified	Available
Form 2 Reviewer Evaluation Form	Form and Instruction	Modified	Available
Form 1 Questions 1-5	Form and Instruction	Modified	Available
Form 3 CERV-Net Pre-Test	Form and Instruction	Modified	Available
Form 2 CERV-Net Post-Test	Form and Instruction	Modified	Available
Form 1 CERV-Net 3-Month Follow-Up Test	Form and Instruction	Modified	Available
Form 2 Website user (site-wide survey)	Form	Modified	Available
Form 1 Website user (page-level survey)	Form	Modified	Available
Form 2 Spanish Language Survey	Form	Modified	Available
Form 1 English Language Survey	Form	Modified	Available
Form 1 Screen Shots of Title V Information System Survey 2021	Form and Instruction	Modified	Available
Form 10 CQI Practicum Completion Survey	Form	Modified	Available
Form 9 Attachment I_CQI Practicum Check in Survey	Form	Modified	Available
Form 8 Attachment H_Quarterly Overall TA Survey	Form	Modified	Available
Form 7 Attachment G_Leadership Academy Completion Survey	Form	Modified	Available
Form 6 Attachment F_Leadership Academy Session Survey	Form	Modified	Available
Form 5 Attachment E_Community of Practice Survey	Form	Modified	Available
Form 4 Attachment D_Webinar Survey	Form	Modified	Available
Form 3 Attachment C_Project Officer Survey	Form	Modified	Available
Form 2 Attachment B_Individualized Targeted TA Closeout	Form	Modified	Available
Form 1 Attachment A_Individualized Targeted TA Check in	Form	Modified	Available
Form 1 Tree Test Script	Form	Modified	Available
Form 2 Telehealth Website - Site Level - Survey EngSpan	Form and Instruction	Modified	Available
Form 1 Telehealth Website - Page Level - SurveyEngSpan	Form and Instruction	Modified	Available
Form 1 0915-0212_UsabiltyTesting Instrument_NPDBSystem	Form and Instruction	Modified	Available
Form 2 User Survey Questions - Query	Form and Instruction	Modified	Available
Form 1 Query Survey Intro-Instructions	Form and Instruction	Modified	Available
Form 1 Donation Experience Survey	Form and Instruction	Modified	Available
Form A Instrument A MIECHV Site Visit Compliance Review Awardee Feedback Form	Form and Instruction	Modified	Available
Form 1 Instrument A MIECHV Site Visit Compliance Review Awardee Feedback Form Boilerplate	Form and Instruction	Modified	Available
Form 1 On Site Compliance Review Awardee Feedback Form	Form	Modified	Available
Form 1 Conference Evaluation Survey	Form	Modified	Available
Form 3 Post Learning Collaborative Survey	Form and Instruction	Modified	Available
Form 2 Instrument B_Post Webinar Survey	Form	Modified	Available
Form 1 Annual Awardee Survey	Form	Modified	Available
Form 1 EHBs Customer Support Center Survey Screenshot	Form and Instruction	Modified	Available
Form 1 EHB Customer Support Center Survey Screenshot	Form and Instruction	Modified	Available
Form Attachment D Attachment D_ECS TACC Semi-Annual Interview Protocol	Form and Instruction	Modified	Available
Form C Attachment C_ECS TACC TA Resources Products Survey	Form and Instruction	Modified	Available
Form B Attachment B_ECS TACC Webinar Survey	Form and Instruction	Modified	Available
Form A Attachment A_ECS TACC Community of Practice Surve	Form and Instruction	Modified	Available
Form 1.2 FORM Reviewer Evaluation-Field Review Q 1 - 12	Form and Instruction	Modified	Available
Form 1 FORM Reviewer Evaluation Q 1- 15	Form	Modified	Available
Form 2 Form Chair Q 1-5	Form	Modified	Available
Form 1.1 Screenshot Reviewer Instr	Form and Instruction	Modified	Available
Form 1 DGMO Customer Service Survey Questions	Form	Modified	Available
0906-0084_MCHB_OMB NonSubstantive Change Request_03052025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-14	Available
0906 0084_NSC Memo.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2026-08-14	Available
Focus Group Example_Screening Questions.docx	Supplementary Document	Uploaded 2024-01-09	Available
Focus Group Example_Informed Consent.docx	Supplementary Document	Uploaded 2024-01-09	Available
Focus Group Example_Focus Group Guide.docx	Supplementary Document	Uploaded 2024-01-09	Available
Supporting Statement B 12.8.23.docx	Supporting Statement B	Uploaded 2024-01-09	Available
Supporting Statement A 12.8.23.docx	Supporting Statement A	Uploaded 2024-01-09	Available
0906-0084_MCHB_OMB NonSubstantive Change Request_03052025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-14	Available
0906 0084_NSC Memo.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-06-28	Available
Focus Group Example_Screening Questions.docx	Supplementary Document	Uploaded 2024-01-09	Available
Focus Group Example_Informed Consent.docx	Supplementary Document	Uploaded 2024-01-09	Available
Focus Group Example_Focus Group Guide.docx	Supplementary Document	Uploaded 2024-01-09	Available
Supporting Statement B 12.8.23.docx	Supporting Statement B	Uploaded 2024-01-09	Available
Supporting Statement A 12.8.23.docx	Supporting Statement A	Uploaded 2024-01-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
282044	FTCA Site Visit Follow-Up Survey	Form	New	FTCA Site Visit Follow-Up Survey
282000	FTCA Office Hours Participant Feedback Survey	Form	Modified	FTCA Office Hours Participant Feedback Survey
278506	HRSA OPTN Patient Service Line Customer Satisfaction Survey	Form	Modified	HRSA OPTN Helpline Customer Satisfaction Survey
271634	Follow up: ASPR/ Strategic National Stockpile (SNS) Dissemination and HRSA-Supported Health Centers use of JYNNEOS vaccine.	Form	Modified	Follow up: ASPR/ Strategic National Stockpile (SNS) Dissemination and HRSA-Supported Health Centers use of JYNNEOS vaccine.
271017	National Maternal Mental Health Hotline	Instruction	Modified
270921	Expanding Health Center Awareness of Sexual Assault-Related Health Care Needs (SATA) Evaluation	Form and Instruction	Modified	Qualitative Interview
270921	Expanding Health Center Awareness of Sexual Assault-Related Health Care Needs (SATA) Evaluation	Form and Instruction	Modified	Post-TA Activity Survey
270921	Expanding Health Center Awareness of Sexual Assault-Related Health Care Needs (SATA) Evaluation	Form and Instruction	Modified	Comprehensive Survey
268809	Technical Assistance to Support the HHS Viral Hepatitis National Strategic Plan	Other-Interview Questions	Modified
267884	HRSA/HIV & AIDS Bureau (HAB) Recipients Satisfaction Survey (RSS).	Form and Instruction	Modified	HAB Recipients Satisfaction Survey
267569	Division of Practitioner Data Bank (DPDB) Webinar Feedback and Satisfaction Surveys	Form	Modified	Webinar Survey Questions
266289	BPHC Customer Service Survey	Form and Instruction	Modified	Customer Feedback Survey
266140	2024 National Ryan White Conference on HIV Care & Treatment Evaluation	Form and Instruction	Modified	Overall 2024 NRWC Conference Evaluation
266140	2024 National Ryan White Conference on HIV Care & Treatment Evaluation	Form	Modified	2024 Ryan White CEU Session Evaluation
266140	2024 National Ryan White Conference on HIV Care & Treatment Evaluation	Form	Modified	2024 NWRC Conference Session Questionaire
266005	HRSA Web Survey	Form	Modified	HRSA Web Survey (Spanish Language)
266005	HRSA Web Survey	Form	Modified	HRSA Web Survey
265734	MIECHV TARC Satisfaction Survey	Form and Instruction	Modified	Individualized Targeted TA
265734	MIECHV TARC Satisfaction Survey	Form and Instruction	Modified	CQI Practicum Completion Survey
265734	MIECHV TARC Satisfaction Survey	Form and Instruction	Modified	Webinar Survey
265734	MIECHV TARC Satisfaction Survey	Form and Instruction	Modified	TARC Meeting Poll
265734	MIECHV TARC Satisfaction Survey	Form and Instruction	Modified	Small Group TA Closeout Survey
265734	MIECHV TARC Satisfaction Survey	Form and Instruction	Modified	Individualized Targeted TA Check in
265734	MIECHV TARC Satisfaction Survey	Form and Instruction	Modified	CQI Practicum Polls
265734	MIECHV TARC Satisfaction Survey	Form and Instruction	Modified	Practicum Check In Survey
265734	MIECHV TARC Satisfaction Survey	Form and Instruction	Modified	Community of Practice Survey Completion Survey
265734	MIECHV TARC Satisfaction Survey	Form and Instruction	Modified	Adaptive Leadership Academy Completion Survey
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q15
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q13-14
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q11-12
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q7-8
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation Q9-10
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q5-6
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q3-4
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation Q1-2
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q11-12
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q9-10
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q7-8
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q5-6
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q3-4
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation- Field Review Q1-2
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Chair Reviewer Evaluation Review Q5
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Chair Reviewer Evaluation Review Form Q3-4
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Chair Reviewer Evaluation Q1-2
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation Field Review
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Reviewer Evaluation Form
265672	DIR Objective Review Assessment Survey	Form and Instruction	Modified	Questions 1-5
265672	DIR Objective Review Assessment Survey	Instruction	Modified
265627	Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation	Form and Instruction	Modified	CERV-Net Pre-Test
265627	Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation	Form and Instruction	Modified	CERV-Net Post-Test
265627	Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation	Form and Instruction	Modified	CERV-Net 3-Month Follow-Up Test
265626	Collection of Qualitative Feedback on Telehealth.HHS.gov	Form	Modified	Website user (site-wide survey)
265626	Collection of Qualitative Feedback on Telehealth.HHS.gov	Form	Modified	Website user (page-level survey)
264362	HRSA Web Survey	Form	Modified	Spanish Language Survey
264362	HRSA Web Survey	Form	Modified	English Language Survey
264361	Title V Information System User Satisfaction Survey	Form and Instruction	Modified	Screen Shots of Title V Information System Survey 2021
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	CQI Practicum Completion Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	Attachment I_CQI Practicum Check in Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	Attachment H_Quarterly Overall TA Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	Attachment G_Leadership Academy Completion Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	Attachment F_Leadership Academy Session Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	Attachment E_Community of Practice Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	Attachment D_Webinar Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	Attachment C_Project Officer Survey
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	Attachment B_Individualized Targeted TA Closeout
264360	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	Attachment A_Individualized Targeted TA Check in
264359	Tree Testing of HRSA's Ryan White HIV/AIDS Program website	Form	Modified	Tree Test Script
264359	Tree Testing of HRSA's Ryan White HIV/AIDS Program website	Other-Tree Test Plan	Modified
264357	Collection of Qualitative Feedback on Telehealth.HHS.gov	Form and Instruction	Modified	Telehealth Website - Site Level - Survey EngSpan
264357	Collection of Qualitative Feedback on Telehealth.HHS.gov	Form and Instruction	Modified	Telehealth Website - Page Level - SurveyEngSpan
264355	National Practitioner Data Bank Usability Survey	Form and Instruction	Modified	0915-0212_UsabiltyTesting Instrument_NPDBSystem
264354	Evaluation Survey of Eligible National Practitioner Data Bank Entity Users: Relevance of Information Collected via NPDB Query Forms	Form and Instruction	Modified	User Survey Questions - Query
264354	Evaluation Survey of Eligible National Practitioner Data Bank Entity Users: Relevance of Information Collected via NPDB Query Forms	Form and Instruction	Modified	Query Survey Intro-Instructions
264353	National Marrow Donor Program Donation Experience Survey	Form and Instruction	Modified	Donation Experience Survey
264352	Maternal, Infant, and Early Childhood Home Visiting Site Visit Awardee Feedback Form	Form and Instruction	Modified	Instrument A MIECHV Site Visit Compliance Review Awardee Feedback Form
264352	Maternal, Infant, and Early Childhood Home Visiting Site Visit Awardee Feedback Form	Form and Instruction	Modified	Instrument A MIECHV Site Visit Compliance Review Awardee Feedback Form Boilerplate
264351	Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form	Form	Modified	On Site Compliance Review Awardee Feedback Form
264349	2024 Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Evaluation Surveys	Form	Modified	Conference Evaluation Survey
264348	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form and Instruction	Modified	Post Learning Collaborative Survey
264348	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	Instrument B_Post Webinar Survey
264348	Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	Form	Modified	Annual Awardee Survey
264347	Health Center Program Support Customer Service Survey	Form and Instruction	Modified	EHBs Customer Support Center Survey Screenshot
264346	HRSA Electronic Handbooks Customer Service Survey	Form and Instruction	Modified	EHB Customer Support Center Survey Screenshot
264345	Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys	Form and Instruction	Modified	Attachment D_ECS TACC Semi-Annual Interview Protocol
264345	Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys	Form and Instruction	Modified	Attachment C_ECS TACC TA Resources Products Survey
264345	Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys	Form and Instruction	Modified	Attachment B_ECS TACC Webinar Survey
264345	Early Childhood Systems Technical Assistance and Coordinating Center Customer Satisfaction Surveys	Form and Instruction	Modified	Attachment A_ECS TACC Community of Practice Surve
264344	Division of Independent Review Objective Review Assessment Survey	Other-Public Burden Statement Screenshot	Modified
264344	Division of Independent Review Objective Review Assessment Survey	Form and Instruction	Modified	FORM Reviewer Evaluation-Field Review Q 1 - 12
264344	Division of Independent Review Objective Review Assessment Survey	Form	Modified	FORM Reviewer Evaluation Q 1- 15
264344	Division of Independent Review Objective Review Assessment Survey	Form	Modified	Form Chair Q 1-5
264344	Division of Independent Review Objective Review Assessment Survey	Form and Instruction	Modified	Screenshot Reviewer Instr
264342	Division of Grants Management Operations Customer Service Satisfaction Survey	Form	Modified	DGMO Customer Service Survey Questions

ICR Details

OMB Control No: 0906-0084	ICR Reference No: 202608-0906-005
Status: Received in OIRA	Previous ICR Reference No: 202503-0906-002
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	Date Submitted to OIRA: 08/27/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	02/28/2027	02/28/2027
Responses	136,977	136,977
Time Burden (Hours)	17,545	15,045
Cost Burden (Dollars)	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: 33

table that charts list of burden

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	Telehealth Website - Page Level - SurveyEngSpan ,   Telehealth Website - Site Level - Survey EngSpan
Collection of Qualitative Feedback on Telehealth.HHS.gov	1, 2	Website user (page-level survey) ,   Website user (site-wide survey)
DIR Objective Review Assessment Survey	2, 1, 3, 1A, 1B, 1C, 3B, 2B, 2C, 2A, 3H, 2D, 2E, 2F, 3A, 3C, 3E, 3D, 3F, 3G	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
Expanding Health Center Awareness of Sexual Assault-Related Health Care Needs (SATA) Evaluation	1, 2, 3	Comprehensive Survey ,   Post-TA Activity Survey ,   Qualitative Interview
FTCA Office Hours Participant Feedback Survey	1	FTCA Office Hours Participant Feedback Survey
FTCA Site Visit Follow-Up Survey	1	FTCA Site Visit Follow-Up Survey
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
Follow up: ASPR/ Strategic National Stockpile (SNS) Dissemination and HRSA-Supported Health Centers use of JYNNEOS vaccine.	1	Follow up: ASPR/ Strategic National Stockpile (SNS) Dissemination and HRSA-Supported Health Centers use of JYNNEOS vaccine.
HRSA Electronic Handbooks Customer Service Survey	1	EHB Customer Support Center Survey Screenshot
HRSA OPTN Patient Service Line Customer Satisfaction Survey	1	HRSA OPTN Helpline Customer Satisfaction Survey
HRSA Web Survey	1, 2	English Language Survey ,   Spanish Language Survey
HRSA Web Survey	1, 2	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	2, 1, 3	Annual Awardee Survey ,   Instrument B_Post Webinar Survey ,   Post Learning Collaborative Survey
Maternal, Infant, and Early Childhood Home Visiting Innovation Technical Assistant Center Satisfaction Surveys	1, 5, 2, 3, 4, 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 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 Maternal Mental Health Hotline
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

table that charts list of burden

	Total Request	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	136,977	0	0	0	0
Annual Time Burden (Hours)	17,545	15,045	0	2,500	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: The current allocation of burden hours for the Umbrella ICR is running low, due to the addition of higher burden hour collections (i.e., collections with above average number of respondents) as well as some previous duplicate collections. Assuming another 5 ICs being submitted this year, HRSA is requesting an additional 2500 burden hours with no increase in the number of burden responses.

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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: 08/27/2026

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