Information Collection

Clinic Staff Interviews

IC 181193 under ICR 200707-0920-003 · OMB 0920-0759.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Clinic Staff Interviews	Form and Instruction
Interview Guide for Clinic Director Attachment C12-Interview Guide Clinic Director.doc	Form and Instruction
Interview Guide for Clinician Provider Attachment C14-Interview Guide Clinician Provider.doc	Form and Instruction
Interview Guide for Care Coordinator Attachment C13-Interview Guide Care Coordinator.doc	Form and Instruction
Interview Guide for Clinic Staff Attachment C15-Interview Guide Clinic Staff.doc	Form and Instruction
Att C16 C17 C19 and C20-Recruitment_Confirmation_Consent.doc Staff Interview Recruitment, Consent and Confirmation Materials	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
Form and Instruction	None	Interview Guide for Clinic Director	Attachment C12-Interview Guide Clinic Director.doc	No	No	Paper Only
Form and Instruction	None	Interview Guide for Clinician Provider	Attachment C14-Interview Guide Clinician Provider.doc	No	No	Paper Only
Form and Instruction	None	Interview Guide for Care Coordinator	Attachment C13-Interview Guide Care Coordinator.doc	No	No	Paper Only
Form and Instruction	None	Interview Guide for Clinic Staff	Attachment C15-Interview Guide Clinic Staff.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Staff Interview Recruitment, Consent and Confirmation Materials	Att C16 C17 C19 and C20-Recruitment_Confirmation_Consent.doc	06/17/2007

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