Health Center Program Support Customer Service 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⚠️ Notice: This information collection may be referencing outdated material.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 0906-0084 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Health Center Program Support Customer Service Survey Form and Instruction
1 EHBs Customer Support Center Survey Screenshot EHBs Customer Support Center Survey Screenshot.docx Form and Instruction
HRSA EHBs Survey Supporting Statement draft 020221.docx Original Generic IC Request IC Document

Information Collection (IC) Details

IC Title:	Health Center Program Support Customer Service 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	EHBs Customer Support Center Survey Screenshot	EHBs Customer Support Center Survey Screenshot.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Original Generic IC Request	HRSA EHBs Survey Supporting Statement draft 020221.docx	01/09/2024

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