Information Collection

Clinical Directors/Supervisors Web-based Survey

IC 198450 under ICR 201107-0930-001 · OMB 0930-0328.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Clinical Director Clinical Directors/Supervisors Web-based Survey	Form and Instruction
Attachment 2.doc	Instruction
Clinical Director Clinical Director Survey Attachment 1.doc	Form and Instruction
Clinical Director Clinical Director Survey Revised Attachment 1.doc	Form and Instruction
Attachments4-10.pdf Attachments 4-10	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	Clinical Director Survey	Clinical Director Survey	Attachment 1.doc	Yes	Yes	Paper Only
Form and Instruction	Clinical Director Survey	Clinical Director Survey Revised	Attachment 1.doc	Yes	Yes	Paper Only
Instruction			Attachment 2.doc	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 569

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	569	569
Annual IC Time Burden (Hours)	569	569
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachments 4-10	Attachments4-10.pdf	06/08/2011

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