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

Documents and forms in this information collection
Document Name	Document Type
Form Attachment 3 Screening, Brief Intervention, Referral and Treatment (SBIRT) Cross-Site Evaluation	Instruction
Attachment 3 Baseline Patient Survey Attachment 3 Patient Baseline Questionnaire.doc	Instruction
Attachment 4 Follow-Up Patient Survey Attachment 4 Patient Follow-up Questionnaire.doc	Form and Instruction
Attachment 5 Practitioner Survey Attachment 5 Pratitioner Questionnaire.doc	Form and Instruction
Attachment 2 Performance Goals.doc Attachment 2 Performance Goals	IC Document
Attachment 8 Patient Informed Consent.doc Attachment 8 Patient Informed Consent	IC Document
Attachment 7 Project Description Handout.doc Attachment 7 Project Description Handout	IC Document
Attachment 9 Network Security at RTI.doc Attachment 9 Network Security at RTI	IC Document
Attachment 10 Confidentiality Pledge.doc Attachment 10 Confidentiality Pledge	IC Document
Attachment 11 Practitioner Informed Consent.doc Attachment 11 Practitioner Informed Consent	IC Document
Attachment 12 Outcome Evaluation Questions.doc Attachment 12 Outcome Evaluation Questions	IC Document
Attachment 13 Table Shells.doc Attachment 13 Table Shells	IC Document
Attachment 14 Table Shell Descriptive Results.doc Attachment 14 Table Shell Descriptive Results	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,861

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,861	0	3,861
Annual IC Time Burden (Hours)	2,960	2,960	0
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.