Information Collection

Staff, Administrators, Supervisors, Providers, Social Workers

IC 219841 under ICR 201601-0930-003 · OMB 0930-0359.

Documents and Forms

Documents and forms in this information collection
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

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.