Community Outreach Worker Profile Form

The HRSA Community Based Outreach Reporting Module

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0064 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Community Outreach Worker Profile Form Form and Instruction
1 Community Outreach Worker Profile Form Community Based Vaccine Outreach Program Reporting Module 07-07-2021.docx www.surveymonkey.com/r/6BTQJC8 Form and Instruction

Information Collection (IC) Details

IC Title:	Community Outreach Worker Profile Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	Community Outreach Worker Profile Form	Community Based Vaccine Outreach Program Reporting Module 07-07-2021.docx	https://www.surveymonkey.com/r/6BTQJC8	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000	Number of Respondents for Small Entity: 131

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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