Information Collection

ealth Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey

IC 260920 under ICR 202306-0915-006 · OMB 0915-0379.

Documents and Forms

Document Name Document Type
Form 1 ealth Center Workforce Survey Evaluation and Technical Assistance: Pilot Survey Form
1 Survey Survey V9_FINAL (2).docx Form
1 Survey Survey V9_FINAL (2).docx Form
FINAL Survey Supporting Statement A.docx Supporting Statement A IC Document
FINAL Survey Supporting Statement A.docx Supporting Statement A IC Document
Final Pilot Survey Supporting Statement B _Update TM_highlighted revisions.docx Supporting Statement B IC Document
Final Pilot Survey Supporting Statement B _Update TM_highlighted revisions.docx Supporting Statement B IC Document
Health Center Workforce Survey Invitation System (Pilot Survey)- Google For.pdf Health Center Workforce Survey Invitation System (Pilot Survey)- Google Form IC Document
Health Center Workforce Survey Invitation System (Pilot Survey)- Google For.pdf Health Center Workforce Survey Invitation System (Pilot Survey)- Google Form IC Document
Health Center Workforce Survey Invitation System (Pilot Survey) Screenshot.png Health Center Workforce Survey Invitation System (Pilot Survey) - Screenshot IC Document
Health Center Workforce Survey Invitation System (Pilot Survey) Screenshot.png Health Center Workforce Survey Invitation System (Pilot Survey) - Screenshot IC Document
HRSA Workforce - Pilot II _ SurveyAnalytics Survey Spanish.pdf HRSA Workforce - Pilot II _ SurveyAnalytics Survey Spanish IC Document
HRSA Workforce - Pilot II _ SurveyAnalytics Survey Spanish.pdf HRSA Workforce - Pilot II _ SurveyAnalytics Survey Spanish IC Document
20220316 English_Spanish HRSA Health Center Workforce Survey and Emails_cl.docx English_Spanish HRSA Health Center Workforce Survey and Emails IC Document
20220316 English_Spanish HRSA Health Center Workforce Survey and Emails_cl.docx English_Spanish HRSA Health Center Workforce Survey and Emails IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	ealth Center Workforce Survey Evaluation and Technical Assistance: Pilot 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	1	Survey	Survey V9_FINAL (2).docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	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	300	300
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	FINAL Survey Supporting Statement A.docx	06/29/2023
Supporting Statement B	Final Pilot Survey Supporting Statement B _Update TM_highlighted revisions.docx	06/29/2023
Health Center Workforce Survey Invitation System (Pilot Survey)- Google Form	Health Center Workforce Survey Invitation System (Pilot Survey)- Google For.pdf	06/29/2023
Health Center Workforce Survey Invitation System (Pilot Survey) - Screenshot	Health Center Workforce Survey Invitation System (Pilot Survey) Screenshot.png	06/29/2023
HRSA Workforce - Pilot II _ SurveyAnalytics Survey Spanish	HRSA Workforce - Pilot II _ SurveyAnalytics Survey Spanish.pdf	06/29/2023
English_Spanish HRSA Health Center Workforce Survey and Emails	20220316 English_Spanish HRSA Health Center Workforce Survey and Emails_cl.docx	06/29/2023

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