Information Collection

Interviews with Clinicians and Office Staff

IC 206888 under ICR 201305-0935-001 · OMB 0935-0212.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #5 Interviews with Clinicians and Office Staff	Form and Instruction
Form #5 Interview Guide for Clinicians and Office Staff Attachment G -- Interview Guide for Clinicians and Office Staff.docx	Form and Instruction
Attachment P -- Information Sheet for Clinicians.docx Attachment P -- Information Sheet for Clinicians	IC Document
Attachment Q -- Information Sheet for Office Staff.docx Attachment Q -- Information Sheet for Office Staff	IC Document

IC Title:

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
Form and Instruction	Form #5	Interview Guide for Clinicians and Office Staff	Attachment G -- Interview Guide for Clinicians and Office Staff.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 114

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	114	114
Annual IC Time Burden (Hours)	114	114
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment P -- Information Sheet for Clinicians	Attachment P -- Information Sheet for Clinicians.docx	05/07/2013
Attachment Q -- Information Sheet for Office Staff	Attachment Q -- Information Sheet for Office Staff.docx	05/07/2013

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