Information Collection

NLM Distance Learning Mentoring Program Study

IC 213754 under ICR 201409-0925-005 · OMB 0925-0476.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0476 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 NLM Distance Learning Mentoring Program Study	Form and Instruction
1 Instruction rating Instrument Attachment 1_ NLM LHC - Instruction Rating Instrument.doc	Form and Instruction
2 Essay Completion Instrument Attachment 2_ NLM LHC - Essay Completion Instrument.docx	Form and Instruction
3 General Inventory Instrument Attachment 3_ NLM LHC - General Inventory Instrument (Kuder Screen Shots).pdf	Form and Instruction
4 Health Inventory Instrument Attachment 4_ NLM LHC - Health Inventory Instrument.docx	Form and Instruction
NLM GC form_ Distance Learning Mentoring_Nov 2014.doc NLM Distance Learning GC Form	IC Document
NLM LHC SSA _Generic Sub-study Nov 2014.docx Mini SSA NLM Distance Learning Mentoring Program Study	IC Document
NLM LHC SSB_Generic Sub-study Nov 2014.doc Mini SSB NLM Distance Learning Mentoring Program Study	IC Document

IC Title:

NLM Distance Learning Mentoring Program Study

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	Instruction rating Instrument	Attachment 1_ NLM LHC - Instruction Rating Instrument.doc	No		Paper Only
Form and Instruction	2	Essay Completion Instrument	Attachment 2_ NLM LHC - Essay Completion Instrument.docx	No		Paper Only
Form and Instruction	3	General Inventory Instrument	Attachment 3_ NLM LHC - General Inventory Instrument (Kuder Screen Shots).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	4	Health Inventory Instrument	Attachment 4_ NLM LHC - Health Inventory Instrument.docx	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	188	188
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NLM Distance Learning GC Form	NLM GC form_ Distance Learning Mentoring_Nov 2014.doc	11/06/2014
Mini SSA NLM Distance Learning Mentoring Program Study	NLM LHC SSA _Generic Sub-study Nov 2014.docx	11/06/2014
Mini SSB NLM Distance Learning Mentoring Program Study	NLM LHC SSB_Generic Sub-study Nov 2014.doc	11/06/2014

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