Information Collection

Peer Workers Survey

IC 213440 under ICR 201410-0930-002 · OMB 0930-0345.

Documents and Forms

Document Name Document Type
Form Core Competency Su Peer Workers Survey Form
Core Competency Su Core Competency Survey Attachment 1 Core competency survey.docx Form
Attachment 3 Data Collection Protocols.docx Data Collection Protocols IC Document
Attachment 4 Letter to Survey Participants.docx Letter to Survey Participants IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Peer Workers Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Core Competency Survey	Core Competency Survey	Attachment 1 Core competency survey.docx		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: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Data Collection Protocols	Attachment 3 Data Collection Protocols.docx	10/09/2014
Letter to Survey Participants	Attachment 4 Letter to Survey Participants.docx	10/09/2014

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