Information Collection

Clinical staff survey

IC 193417 under ICR 201006-0935-001 · OMB 0935-0167.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #3 Clinical staff survey	Form and Instruction
Form #3 Placeholder for clinical staff questionnaire Attachment F -- Placeholder for clinical staff questionnaire.docx	Form and Instruction
Attachment E -- Cover letter for employee survey.docx Attachment E -- Cover letter for employee survey	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #3	Placeholder for clinical staff questionnaire	Attachment F -- Placeholder for clinical staff questionnaire.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3

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	30	30
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment E -- Cover letter for employee survey	Attachment E -- Cover letter for employee survey.docx	06/04/2010

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