Information Collection

Clinic Staff Survey

IC 227358 under ICR 201706-0920-012 · OMB 0920-1211.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Clinic Staff Survey - PHC Evaluation - Att 10 Clinic Staff Survey	Form and Instruction
Clinic Staff Survey - PHC Evaluation - Att 10 Att 10 Clinic Staff Survey_06.14.17.docx	Form and Instruction

IC Title:

Clinic Staff Survey

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	NA			NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	80	80
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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