HRSA Web 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 HRSA Web Survey Form
Form 1 HRSA Web Survey Form
1 HRSA Web Survey HRSA Website Survey (Clean Copy).docx 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
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
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
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
hrsa-approved-survey-questions-final_ES (in track changes).docx Revised Spanish Language Survey (Track Changes) IC Document

Information Collection (IC) Details

IC Title:	HRSA Web 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	1	HRSA Web Survey	HRSA Website Survey (Clean Copy).docx		Yes	Yes	Fillable Fileable
Form	2	HRSA Web Survey (Spanish Language)	hrsa-approved-survey-questions-final_ES (clean copy).docx		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 %

	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

Title	Document	Date Uploaded
HRSA Web Survey Redline	HRSA Website Survey (Revised Tracked Changes).docx	03/26/2024
Fast Track Request	fast-track-hrsa-web-survey-20240304 .docx	03/26/2024
Revised Spanish Language Survey (Track Changes)	hrsa-approved-survey-questions-final_ES (in track changes).docx	03/26/2024

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