Information Collection

Provider Staff Supervisior/Admin.

IC 199304 under ICR 201109-0930-001 · OMB 0930-0332.

Documents and Forms

Document Name Document Type
Form Provider Site Visi Provider Staff Supervisior/Admin. Form and Instruction
Provider Site Visi Provider Site Visit Interview Guide Attachment_B_PATH_Provider_Site_Visit_Interview_Guide_Supervisor_Administrator[1].docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider Staff Supervisior/Admin.	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Provider Site Visit Interview Guide	Provider Site Visit Interview Guide	Attachment_B_PATH_Provider_Site_Visit_Interview_Guide_Supervisor_Administrator[1].docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	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	10	10
Annual IC Time Burden (Hours)	7	7
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.