NHSC Site Retention Assessment Questionnaire

Forms and Documents

Document Name	Status
Form 1 NHSC Site Retention Assessment Questionnaire Form and Instruction	New
NHSC Site Ret Questionnaire_pilot report_final.docx Supplementary Document	2013-07-18
Supporting Stmt B_NHSC Site Ret Assess Questionnaire_070913.doc Supplementary Document	2013-07-18
Supporting Statement.doc Supporting Statement A	2013-02-06

IC Document Collections

IC ID	Document Title	Status
205949	NHSC Site Retention Assessment Questionnaire Form and Instruction	New

ICR Details

OMB Control No: 0915-0372	ICR Reference No: 201302-0915-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No: 18771
Title: NHSC Site Retention Assessment Questionnaire
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/18/2013
	Date Received in OIRA: 02/27/2013
Terms of Clearance: HRSA is reminded that while the methodology used in this initiative can be helpful to identify themes and areas for future exploration, it is not adequate to allow HRSA to draw conclusions about what influences physician retention.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2016	36 Months From Approved
Responses	7,000	0	0
Time Burden (Hours)	3,549	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of the NHSC Site Retention Assessment Questionnaire is to collect survey information from administrative officials at NHSC sites that will guide NHSC initiatives and assist sites in improving their retention outcomes. The survey will ask site administrators to rate how difficult it is to retain clinicians, their general attitudes about the feasibility of good retention and awareness of its principles, their practices' current approaches to promoting retention, ratings on various aspects of their practices' organizational culture and administrative style, and their sites' interest in and preferred ways of learning how to bolster retention. Survey data will be gathered anonymously and presented in-aggregate, to promote administrators' participation and full disclosure.

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Authorizing Statute(s): US Code: 42 USC 254f Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 67656	11/13/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 11656	02/19/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
NHSC Site Retention Assessment Questionnaire	1	NHSC Site Retention Assessment Questionnaire

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	7,000	0	0	7,000	0	0
Annual Time Burden (Hours)	3,549	0	0	3,549	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $70,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/27/2013

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