Information Collection

Clinic Staff Script - Approaching Clients

IC 200564 under ICR 201112-0920-015 · OMB 0920-0922.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0922 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Rev Attachment 7d_Clinic Staff-Approaching Clients.doc	Instruction
Attach 9b Clinic Survey Interviewer Script.docx Attachment 9b Clinic Survey Interviewer Script	IC Document
Attach 7a _Clinic Director Script.doc Attachment 7a Clinic Director Script	IC Document

IC Title:

Clinic Staff Script - Approaching Clients

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Rev Attachment 7d_Clinic Staff-Approaching Clients.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	1,100	1,100
Annual IC Time Burden (Hours)	92	92
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 9b Clinic Survey Interviewer Script	Attach 9b Clinic Survey Interviewer Script.docx	12/20/2011
Attachment 7a Clinic Director Script	Attach 7a _Clinic Director Script.doc	12/20/2011

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