Staff, Administrators, Supervisors, Providers, Social Workers

Screening, Brief Intervention, and Referral to Treatment (SBIRT) Cross-Site Evaluation

Documents and Forms

Document Name Document Type
Form Performance Site S Staff, Administrators, Supervisors, Providers, Social Workers Form and Instruction
Performance Site S Performance Site Survey Attachment 1 - Performance site survey_10-20-15.docx Form and Instruction
Attachment 2- Network security at RTI_10-20-15.doc Network Security at RTI IC Document
Attachment 3 - Privacy pledge.doc Privacy Pledge IC Document
Attachment 4 - Performance site survey consent script.doc Consent IC Document
Attachment 5 - Table shells for descriptive results.doc Table Shells IC Document

Information Collection (IC) Details

IC Title:	Staff, Administrators, Supervisors, Providers, Social Workers	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 and Instruction	Performance Site Survey	Performance Site Survey	Attachment 1 - Performance site survey_10-20-15.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,407	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	1,407	1,407
Annual IC Time Burden (Hours)	310	310
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Network Security at RTI	Attachment 2- Network security at RTI_10-20-15.doc	01/27/2016
Privacy Pledge	Attachment 3 - Privacy pledge.doc	01/27/2016
Consent	Attachment 4 - Performance site survey consent script.doc	01/27/2016
Table Shells	Attachment 5 - Table shells for descriptive results.doc	01/27/2016

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