Customer Feedback Survey

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Customer Feedback Survey Form and Instruction
Form 1 Customer Feedback Survey Form and Instruction
1 Customer Feedback Survey BPHC Customer Feedback Survey.final.docx Form and Instruction
1 Customer Feedback Survey BPHC Customer Feedback Survey.final.docx Form and Instruction
Fast track Memo_May.docx Customer Feedback Fast Track IC Document
Fast track Memo_May.docx Customer Feedback Fast Track IC Document

Information Collection (IC) Details

IC Title:	Customer Feedback Survey	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Customer Feedback Survey	BPHC Customer Feedback Survey.final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,844	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,844	1,844
Annual IC Time Burden (Hours)	154	154
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Customer Feedback Fast Track	Fast track Memo_May.docx	05/24/2023

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