Division of Independent Review Objective Review Assessment Survey

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

Documents and Forms

Document Name Document Type
Form 1.1 Division of Independent Review Objective Review Assessment Survey Form and Instruction
Public Burden Statement Screenshot.pdf Other-Public Burden Statement Screen
Public Burden Statement Screenshot.pdf Other-Public Burden Statement Screen
1.1 Screenshot Reviewer Instr DIR Review Assessment Survey form 1 - screenshot Reviewer instr.pdf Form and Instruction
1.1 Screenshot Reviewer Instr DIR Review Assessment Survey form 1 - screenshot Reviewer instr.pdf Form and Instruction
2 Form Chair Q 1-5 FORM CHAIR Q 1-5.pdf Form
2 Form Chair Q 1-5 FORM CHAIR Q 1-5.pdf Form
1 FORM Reviewer Evaluation Q 1- 15 FORM Reviewer Evaluation Q 1- 15.pdf Form
1 FORM Reviewer Evaluation Q 1- 15 FORM Reviewer Evaluation Q 1- 15.pdf Form
1.2 FORM Reviewer Evaluation-Field Review Q 1 - 12 FORM Reviewer Evaluation-Field Review Q 1 - 12.pdf Form and Instruction
1.2 FORM Reviewer Evaluation-Field Review Q 1 - 12 FORM Reviewer Evaluation-Field Review Q 1 - 12.pdf Form and Instruction
Supporting Statement A - DIR Review Assessment Surve.docx Original Generic Request IC Document
Supporting Statement A - DIR Review Assessment Surve.docx Original Generic Request IC Document

Information Collection (IC) Details

IC Title:	Division of Independent Review Objective Review Assessment Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1.1	Screenshot Reviewer Instr	DIR Review Assessment Survey form 1 - screenshot Reviewer instr.pdf	Yes	Yes	Fillable Fileable
Form	2	Form Chair Q 1-5	FORM CHAIR Q 1-5.pdf	Yes	Yes	Fillable Fileable
Form	1	FORM Reviewer Evaluation Q 1- 15	FORM Reviewer Evaluation Q 1- 15.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1.2	FORM Reviewer Evaluation-Field Review Q 1 - 12	FORM Reviewer Evaluation-Field Review Q 1 - 12.pdf	Yes	Yes	Fillable Fileable
Other-Public Burden Statement Screenshot			Public Burden Statement Screenshot.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,300	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,300	2,300
Annual IC Time Burden (Hours)	575	575
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Original Generic Request	Supporting Statement A - DIR Review Assessment Surve.docx	01/09/2024

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