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

Forms and Documents

Document Name	Status
Form 1 Collection of Qualitative Feedback on Telehealth.HHS.gov Form	New
Form 1 Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form Form	New
Form 1 HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach Form and Instruction	New
Form 1 Maternal and Child Health Nutrition Training Needs Assessment Form and Instruction	New
Form 1 National Practitioner Data Bank Call Center Customer Satisfaction Survey Form	New
Form 1 National Practitioner Data Bank (NPDB) Usability Surveys Form and Instruction	New
Form 1 Donation Experience Survey Form and Instruction	New
Form 1 Virtual Interviews with Members of the Public to Assess Customer Experience with Organ Donation PSAs Form and Instruction	New
Form 1 2020 National Ryan White Conference on HIV Care and Treatment Form and Instruction	New
Form 1 OAMP Customer Satisfaction Survey Form	New
Form A (MIECHV MODS) Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) Developing Strategies to Facilitate Cross-Model Collaboration and Data Sharing – Customer Satisfaction Survey Forms Form	New
Form 1 Health Center Program Support Customer Service Survey Form	New
Form 1 Division of Practitioner Data Bank (DPDB) Feedback and Satisfaction Surveys Form	New
Form 1 DGMO Customer Service Satisfaction Survey Form	New
Form 1 HRSA Division of Practitioner Data Bank (DPDB) 2019 Education Forum Participant Survey Form and Instruction	New
Form A Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form Form	New
Form 1 UDS Reporting Modernization Customer Satisfaction Survey Form and Instruction	New
Form A Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Feedback Forms Form	New
Form 1 2018 National Ryan White Conference on HIV Care & Treatment Evaluation Form and Instruction	New
Form B Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys Form	New
Form A Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys Form	New
Form 1 Maternal and Child Health Epidemiology Training Course One-Year Follow-up Survey Form	New
Form 1 Title V Information System (TVIS) User Satisfaction Survey Form and Instruction	New
Form 1 DIR Objective Peer Review Assessment Survey Form and Instruction	New
Form 1 Building Futures: Supporting Youth Living with HIV, Feedback on Toolkit and Webinars Form	New
Example0212 focus.doc Supplementary Document	2018-05-07
Example Focus Group HSB.docx Supplementary Document	2018-05-07
Example Customer Survey OFAM.pdf Supplementary Document	2018-05-07
Example Customer Survey BHW.pdf Supplementary Document	2018-05-07
Supporting Statement - part B.docx Supporting Statement B	2018-05-07
Supporting Statement A FINAL 7-18.docx Supporting Statement A	2018-07-05

IC Document Collections

IC ID	Document Title	Status
243803	Collection of Qualitative Feedback on Telehealth.HHS.gov Form	New
243729	Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form Form	New
243367	HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach Form and Instruction	New
242705	Maternal and Child Health Nutrition Training Needs Assessment Form and Instruction	New
242662	National Practitioner Data Bank Call Center Customer Satisfaction Survey Form	New
242595	National Practitioner Data Bank (NPDB) Usability Surveys Form and Instruction	New
241938	Donation Experience Survey Form and Instruction	New
241894	Virtual Interviews with Members of the Public to Assess Customer Experience with Organ Donation PSAs Form and Instruction	New
241510	2020 National Ryan White Conference on HIV Care and Treatment Form and Instruction	New
240443	OAMP Customer Satisfaction Survey Form	New
240006	(MIECHV MODS) Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) Developing Strategies to Facilitate Cross-Model Collaboration and Data Sharing – Customer Satisfaction Survey Forms Form	New
238306	Health Center Program Support Customer Service Survey Form	New
237840	Division of Practitioner Data Bank (DPDB) Feedback and Satisfaction Surveys Form	New
236621	DGMO Customer Service Satisfaction Survey Form	New
235410	HRSA Division of Practitioner Data Bank (DPDB) 2019 Education Forum Participant Survey Form and Instruction	New
235352	Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form Form	New
234766	UDS Reporting Modernization Customer Satisfaction Survey Form and Instruction	New
234377	Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Feedback Forms Form	New
233091	2018 National Ryan White Conference on HIV Care & Treatment Evaluation Form and Instruction	New
232942	Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys Form	New
232937	Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys Form	New
232590	Maternal and Child Health Epidemiology Training Course One-Year Follow-up Survey Form	New
232547	Title V Information System (TVIS) User Satisfaction Survey Form and Instruction	New
232505	DIR Objective Peer Review Assessment Survey Form and Instruction	New
232123	Building Futures: Supporting Youth Living with HIV, Feedback on Toolkit and Webinars Form	New

ICR Details

OMB Control No: 0915-0212	ICR Reference No: 201506-0915-001
Status: Historical Active	Previous ICR Reference No: 201502-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/06/2018
	Date Received in OIRA: 05/15/2018
Terms of Clearance: The agency is reminded that individual packages submitted under this generic clearance must be reviewed and approved by OMB prior to fielding. OMB will seek to review surveys within 10 days of submission. Packages submitted under this clearance will be used solely for purposes of measuring customer satisfaction.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2021	05/31/2018	07/31/2018
Responses	52,250	0	52,250
Time Burden (Hours)	5,375	0	5,375
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:
	82 FR 52308	11/13/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 18574	04/27/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 25

IC Title	Form No.	Form Name
National Practitioner Data Bank Call Center Customer Satisfaction Survey	1	NPDB Customer Survey Questions.docx
HRSA Division of Transplantation (DoT) Formative Evaluation Minority Organ Donation Outreach	1, 2	FORM Focus Group CLEAN.docx ,   FORM Survey Questions CLEAN.docx
Title V Information System (TVIS) User Satisfaction Survey	1	Screen Shots of Title V Information System Survey 2018.docx
HRSA Division of Practitioner Data Bank (DPDB) 2019 Education Forum Participant Survey	1	2019 NPDB Education Forum Feedback Survey.pdf
2018 National Ryan White Conference on HIV Care & Treatment Evaluation	1, 3, 2, 4	Ryan White 2018 Session Evaluation 9.18.2018 FINAL2.pdf ,   Breakout Session Evaluation Questions_final.docx ,   Plenary Session Evaluation Questions_final.docx ,   Overall 2018 NRWC Evaluation_final.docx
Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	C, E, A, B, D	Attachment A-Annual Satisfaction Survey.docx ,   Attachment B-HV-ImpACT Event Survey.docx ,   Attachment C-Community of Practice Survey.docx ,   Attachment D-Targeted TA Project Officer survey.docx ,   Attachment E-Newsletter Survey.docx
2020 National Ryan White Conference on HIV Care and Treatment	1, 3, 2, 4	Overall 2020 NRWC Conference Evaluation.docx ,   2020 NWRC Breakout Evaluation Questions for App.docx ,   2020 NWRC Plenary Evaluation Questions for App.docx ,   2020 Ryan White CEU Session Evaluation Form.docx
Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form	1	MIECHV On-Site Compliance Review Awardee Feedback Form.docx
(MIECHV MODS) Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) Developing Strategies to Facilitate Cross-Model Collaboration and Data Sharing – Customer Satisfaction Survey Forms	C, A, B	Attachment A - Data Science Training Survey.docx ,   Attachment B - Resource Guide Survey.docx ,   Attachment C - List of Analytic Experts Survey.docx
UDS Reporting Modernization Customer Satisfaction Survey	1	UDS Reporting Modernization Customer Satisfaction Survey
Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys	A, B, C, D	Attachment B - HV-PMCQI Information Request Survey.docx ,   Attachment C - HV-PMCQI Individualized TA Survey.docx ,   Attachment D - HV-PMCQI Webinar Survey.docx ,   Attachment A - HV-PMCQI Annual Survey.docx
Health Center Program Support Customer Service Survey	1	Sample Customer Service Survey--Salesforce In Test.docx
Maternal and Child Health Nutrition Training Needs Assessment	1	Survey MCH Nutrition Training Needs Assessment.docx
DGMO Customer Service Satisfaction Survey	1	DGMO Customer Service Survey Questions.docx
Donation Experience Survey	1 R, 1	New Survey - Be The Match Donation Experience Generic.docx ,   Old Survey Redline - Be The Match Donation Experience Generic.docx
Maternal and Child Health Epidemiology Training Course One-Year Follow-up Survey	1	One-Year Trainee Survey form.docx
Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form	A	Attachment A-MIECHV On-Site Compliance Review Awardee Feedback Form.docx
OAMP Customer Satisfaction Survey	1	Example Survey in Survey Monkey - OAMP.pdf
Building Futures: Supporting Youth Living with HIV, Feedback on Toolkit and Webinars	1	BF_Webinar_Survey_4_24_2018.docx
DIR Objective Peer Review Assessment Survey	1Q5, 1Q4, 1Q3, 1, 2Q1, 1Q2, 1Q1, 2Q2	0212 DIR OMB Survey Binder 8-1-18.pdf - SHOWS BURDEN STMNT, OMB NO AND EXP DATE ,   DIR Review Assessment Survey form 1 - screenshot Reviwer Q1.png ,   DIR Review Assessment Survey form 1 - screenshot ReviewerQ2.png ,   DIR Review Assessment Survey form 1 - screenshot Reviwer3.png ,   DIR Review Assessment Survey form 1 - screenshot ReviwerQ4.png ,   DIR Review Assessment Survey form 1 - screenshot ReviwerQ5.png ,   DIR Review Assessment Survey form 2 - screenshot ChairQ 1.png ,   DIR Review Assessment Survey form 2 - screenshot Chair ReviewQ2.png
Virtual Interviews with Members of the Public to Assess Customer Experience with Organ Donation PSAs	1	Interview Guide - OMB Outreach Evaluations CLEAN.RA.docx
Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Feedback Forms	A, B	All Grantee Meeting Feedback ,   All Grantee Meeting Individual Session Feeback
Division of Practitioner Data Bank (DPDB) Feedback and Satisfaction Surveys	1	National Practitioner Data Bank (NPDB) Webcast Survey
Collection of Qualitative Feedback on Telehealth.HHS.gov	1, 2	Telehealth Website - Page Level - SurveyEngSpan.docx ,   Telehealth Website - Site Level - Survey EngSpan.docx
National Practitioner Data Bank (NPDB) Usability Surveys	1	National Practitioner Data Bank (NPDB) Usability Surveys

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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	52,250	52,250	0	0	0	0
Annual Time Burden (Hours)	5,375	5,375	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $700,000

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? Uncollected

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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: 05/15/2018

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