Information Collection

Practicum Participant Survey

IC 202135 under ICR 201112-0925-001 · OMB 0925-0648.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Practicum Participant Survey	Form and Instruction
1 Practicum Participant Survey Practicum Survey Screen Shots_03202012.docx	Form and Instruction
Practicum Survey Invitation Screen Shot_03202012.docx Practicum Survey Invitation Screen Shot_03202012	IC Document
Fast Track Template ODS Survey Request for Approval _ March_ 20_ 2012.doc Fast Track Template ODS Survey Request for Approval _ March_ 20_ 2012	IC Document
Word Version ODS_Practicum Eval_Final Survey_03202012.docx Word Version ODS_Practicum Eval_Final Survey_03202012	IC Document

IC Title:

Practicum Participant Survey

Agency IC Tracking Number:

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
Form and Instruction	1	Practicum Participant Survey	Practicum Survey Screen Shots_03202012.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 381

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 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	381	0	0	0	0	0
Annual IC Time Burden (Hours)	159	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Practicum Survey Invitation Screen Shot_03202012	Practicum Survey Invitation Screen Shot_03202012.docx	05/01/2012
Fast Track Template ODS Survey Request for Approval _ March_ 20_ 2012	Fast Track Template ODS Survey Request for Approval _ March_ 20_ 2012.doc	05/01/2012
Word Version ODS_Practicum Eval_Final Survey_03202012	Word Version ODS_Practicum Eval_Final Survey_03202012.docx	05/01/2012

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