OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Screening, Brief Intervention, Referral and Treatment (SBIRT) Cross-Site Evaluation

IC 45188 under ICR 200609-0930-002 · OMB 0930-0282.

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Screening, Brief Intervention, Referral and Treatment (SBIRT) Cross-Site Evaluation
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Attachment 3 Baseline Patient Survey Attachment 3 Patient Baseline Questionnaire.doc Yes Yes Paper Only
Form and Instruction Attachment 4 Follow-Up Patient Survey Attachment 4 Patient Follow-up Questionnaire.doc Yes Yes Paper Only
Form and Instruction Attachment 5 Practitioner Survey Attachment 5 Pratitioner Questionnaire.doc Yes Yes Printable Only

Health Health Care Services

 

3,861 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,861 0 3,861 0 0 0
Annual IC Time Burden (Hours) 2,960 2,960 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment 2 Performance Goals Attachment 2 Performance Goals.doc 08/01/2006
Attachment 8 Patient Informed Consent Attachment 8 Patient Informed Consent.doc 08/01/2006
Attachment 7 Project Description Handout Attachment 7 Project Description Handout.doc 08/01/2006
Attachment 9 Network Security at RTI Attachment 9 Network Security at RTI.doc 08/01/2006
Attachment 10 Confidentiality Pledge Attachment 10 Confidentiality Pledge.doc 08/01/2006
Attachment 11 Practitioner Informed Consent Attachment 11 Practitioner Informed Consent.doc 08/01/2006
Attachment 12 Outcome Evaluation Questions Attachment 12 Outcome Evaluation Questions.doc 08/01/2006
Attachment 13 Table Shells Attachment 13 Table Shells.doc 08/01/2006
Attachment 14 Table Shell Descriptive Results Attachment 14 Table Shell Descriptive Results.doc 08/01/2006
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.