Information Collection

Practitioners

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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.