Information Collection

Community and Clinical Partner Program Implementation Partner Needs Assessment

IC 203972 under ICR 201409-0920-009 · OMB 0920-0952.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Community and Clinical Partner Program Implementation Partner Needs Assessment	Form and Instruction
Att 5 Com and Clinical Partners Prog Implem Partner Need Att 5 Com and Clinical Partners Prog Implem Partner Needs Assmt.Revised.docx	Form and Instruction
0920-0952 Attachment 5 (electronic) Attachment 5 (electronic).pdf	Form and Instruction
Att 12. Clinical Component Best Practices.docx Att 12	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	N/A	Att 5 Com and Clinical Partners Prog Implem Partner Needs Assmt.Revised	Att 5 Com and Clinical Partners Prog Implem Partner Needs Assmt.Revised.docx		No	No	Paper Only
Form and Instruction	0920-0952	Attachment 5 (electronic)	Attachment 5 (electronic).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 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	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	75	75
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 12	Att 12. Clinical Component Best Practices.docx	09/04/2012

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