Information Collection

Practitioners

IC 197695 under ICR 201105-0930-002 · OMB 0930-0327.

Documents and Forms

Document Name Document Type
Form Attachment D_Follo Practitioners Form and Instruction
Attachment B_ Base Attachment B_ Baseline Survey Staff Attachment B_ Baseline Survey, Staff Version_Final_with OMB changes.doc Form and Instruction
Attachment D_Follo Attachment D_Followup Survey Staff Attachment D_Followup Survey, Staff Version_Final_with OMB changes.doc Form and Instruction
Attachment E_Evalu Attachment E_Evaluation Attachment E_Evaluation Survey_Packets_Final_with OMB changes.doc Form and Instruction
Attachment F_Evalu Attachment F_Evaluation Attachment F_Evaluation Survey_Training Webinar_Final_with OMB changes.doc Form and Instruction
Attachment G_Evalu Attachment G_Evaluation Attachment G_Evaluation Survey_Coaching Webinar_Final_with OMB changes.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Practitioners	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Attachment D_Followup Survey Staff	Attachment D_Followup Survey Staff	Attachment D_Followup Survey, Staff Version_Final_with OMB changes.doc	Yes	Yes	Paper Only
Form and Instruction	Attachment B_ Baseline Survey Staff	Attachment B_ Baseline Survey Staff	Attachment B_ Baseline Survey, Staff Version_Final_with OMB changes.doc	Yes	Yes	Paper Only
Form and Instruction	Attachment E_Evaluation	Attachment E_Evaluation	Attachment E_Evaluation Survey_Packets_Final_with OMB changes.doc	Yes	Yes	Paper Only
Form and Instruction	Attachment F_Evaluation	Attachment F_Evaluation	Attachment F_Evaluation Survey_Training Webinar_Final_with OMB changes.doc	Yes	Yes	Paper Only
Form and Instruction	Attachment G_Evaluation	Attachment G_Evaluation	Attachment G_Evaluation Survey_Coaching Webinar_Final_with OMB changes.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	552	552
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.