Information Collection

Clinician and Adolescent Feedback for the Development of an Adolescent Substance Use Continuing Medical Education/Continuing Education (CME/CE) Program

IC 215689 under ICR 201202-0925-001 · OMB 0925-0655.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0655 can be found here:

2015-03-27 - Extension without change of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Clinician Survey Clinician and Adolescent Feedback for the Development of an Adolescent Substance Use Continuing Medical Education/Continuing Education (CME/CE) Program	Form and Instruction
Form 1 Pharmacist Survey Clinician and Adolescent Feedback for the Development of an Adolescent Substance Use Continuing Medical Education/Continuing Education (CME/CE) Program	Form and Instruction
Form 1 Adolescent Survey Clinician and Adolescent Feedback for the Development of an Adolescent Substance Use Continuing Medical Education/Continuing Education (CME/CE) Program	Form and Instruction
1 Clinician Survey 2 - Clinician Survey Screenshots.docx	Form and Instruction
1 Pharmacist Survey 3 - Pharmacist Survey Screenshots.docx	Form and Instruction
1 Adolescent Survey 4 - Adolescent Survey Screenshots.docx	Form and Instruction
1 - OMB Application-Template 3-13-15_NIDAMED Fast Track Revised.doc Fast Track Submission Form	IC Document
5 - Consent Forms (2)_3-5-15_NIDA revised.docx Consent Form	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Clinician and Adolescent Feedback for the Development of an Adolescent Substance Use Continuing Medical Education/Continuing Education (CME/CE) Program

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Clinician Survey	2 - Clinician Survey Screenshots.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1	Pharmacist Survey	3 - Pharmacist Survey Screenshots.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1	Adolescent Survey	4 - Adolescent Survey Screenshots.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,475

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,475	5,475
Annual IC Time Burden (Hours)	627	627
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Submission Form	1 - OMB Application-Template 3-13-15_NIDAMED Fast Track Revised.doc	03/16/2015
Consent Form	5 - Consent Forms (2)_3-5-15_NIDA revised.docx	03/16/2015

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