Information Collection

HRSA Web Survey

IC 266005 under ICR 202608-0906-005 · OMB 0906-0084.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 HRSA Web Survey HRSA Web Survey	Form
Form 2 HRSA Web Survey (Spanish Language) HRSA Web Survey	Form
1 HRSA Web Survey HRSA Website Survey (Clean Copy).docx	Form
2 HRSA Web Survey (Spanish Language) hrsa-approved-survey-questions-final_ES (clean copy).docx	Form
HRSA Website Survey (Revised Tracked Changes).docx HRSA Web Survey Redline	IC Document
fast-track-hrsa-web-survey-20240304 .docx Fast Track Request	IC Document
hrsa-approved-survey-questions-final_ES (in track changes).docx Revised Spanish Language Survey (Track Changes)	IC Document

IC Title:

HRSA Web Survey

Agency IC Tracking Number:

IC Status: Modified

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
HRSA Web Survey Redline		03/26/2024
Fast Track Request		03/26/2024
Revised Spanish Language Survey (Track Changes)		03/26/2024

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

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