Information Collection

Primary Care Providers

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Demographics Primary Care Providers	Form and Instruction
Form 3 Clincal Practices Assessment Primary Care Providers	Form and Instruction
Form 4 Clincal Practices Intentions Primary Care Providers	Form and Instruction
Form 6 SBIRT Attitudes Primary Care Providers	Form and Instruction
Form 7 SBIRT Self Efficency Primary Care Providers	Form and Instruction
Form 8 SBIRT Perceived Barriers Primary Care Providers	Form and Instruction
Form 9 Satistfaction Questionaire Primary Care Providers	Form and Instruction
Form 11 Eligibility Screening Primary Care Providers	Form and Instruction
Form 2 Knowledge Test Primary Care Providers	Form and Instruction
Form 5 VSPE Primary Care Providers	Form and Instruction
Form 10 SP Profile Primary Care Providers	Form and Instruction
Form 18 Sample Copy HHS Impact Assessment Primary Care Providers	Form and Instruction
3 Clincal Practices Assessment Attachment8_ClinicalPracticesAssessment (2).doc	Form and Instruction
4 Clincal Practices Intentions Attachment9_ClinicalPracticeIntentions (2).doc	Form and Instruction
6 SBIRT Attitudes Attachment 11_SBIRTAttitudesQ (2).DOC	Form and Instruction
7 SBIRT Self Efficency Attachment 12_SBIRTSelfEfficacyQ.DOC	Form and Instruction
8 SBIRT Perceived Barriers Attachment 13_SBIRTPerceivedBarriersQ.doc	Form and Instruction
9 Satistfaction Questionaire Attachment14_SatisfactionQuestionnaires-April.pdf	Form and Instruction
11 Eligibility Screening Attachment3_EligibilityScreening.doc	Form and Instruction
1 Demographics Attachment6_Demographics11 2 11.doc	Form and Instruction
2 Knowledge Test Attachment7_KnowledgeTests 11 2 11.doc	Form and Instruction
5 VSPE Attachment 10_VSPEs 11 2 11.doc	Form and Instruction
10 SP Profile Attachment 15_SP-Profile 11 2 11.doc	Form and Instruction
18 Sample Copy HHS Impact Assessment Attachment 18 SAMPLE COPY HHS IMPACT ASSESSMENT.doc	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Primary Care Providers

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Yes	Yes	Fillable Fileable
Form and Instruction	4	Yes	Yes	Fillable Fileable
Form and Instruction	6	Yes	Yes	Fillable Fileable
Form and Instruction	7	Yes	Yes	Fillable Fileable
Form and Instruction	8	Yes	Yes	Fillable Fileable
Form and Instruction	9	Yes	Yes	Fillable Fileable
Form and Instruction	11	Yes	Yes	Fillable Fileable
Form and Instruction	1	Yes	Yes	Fillable Fileable
Form and Instruction	2	Yes	Yes	Fillable Fileable
Form and Instruction	5	Yes	Yes	Fillable Fileable
Form and Instruction	10	Yes	Yes	Fillable Fileable
Form and Instruction	18	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 94

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	94	94
Annual IC Time Burden (Hours)	188	188
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.

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