OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Primary Care Providers

IC 199009 under ICR 201108-0925-004 · OMB 0925-0646.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Primary Care Providers
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 Demographics Attachment6_Demographics11 2 11.doc Yes Yes Fillable Fileable
Form and Instruction 3 Clincal Practices Assessment Attachment8_ClinicalPracticesAssessment (2).doc Yes Yes Fillable Fileable
Form and Instruction 4 Clincal Practices Intentions Attachment9_ClinicalPracticeIntentions (2).doc Yes Yes Fillable Fileable
Form and Instruction 6 SBIRT Attitudes Attachment 11_SBIRTAttitudesQ (2).DOC Yes Yes Fillable Fileable
Form and Instruction 7 SBIRT Self Efficency Attachment 12_SBIRTSelfEfficacyQ.DOC Yes Yes Fillable Fileable
Form and Instruction 8 SBIRT Perceived Barriers Attachment 13_SBIRTPerceivedBarriersQ.doc Yes Yes Fillable Fileable
Form and Instruction 9 Satistfaction Questionaire Attachment14_SatisfactionQuestionnaires-April.pdf Yes Yes Fillable Fileable
Form and Instruction 11 Eligibility Screening Attachment3_EligibilityScreening.doc Yes Yes Fillable Fileable
Form and Instruction 10 SP Profile Attachment 15_SP-Profile 11 2 11.doc Yes Yes Fillable Fileable
Form and Instruction 5 VSPE Attachment 10_VSPEs 11 2 11.doc Yes Yes Fillable Fileable
Form and Instruction 2 Knowledge Test Attachment7_KnowledgeTests 11 2 11.doc Yes Yes Fillable Fileable
Form and Instruction 18 Sample Copy HHS Impact Assessment Attachment 18 SAMPLE COPY HHS IMPACT ASSESSMENT.doc Yes Yes Fillable Fileable

Health Consumer Health and Safety

 

94 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 94 0 94 0 0 0
Annual IC Time Burden (Hours) 188 0 188 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.