Information Collection

Adolescent SBIRT (A-SBIRT) Online Training (Kognito) Feedback Surveys

IC 229754 under ICR 201708-0990-001 · OMB 0990-0379.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0379 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Wheeler Clinic Kognito_CT SBI with Adolescents - Follow up_Survey 5-21-18.pdf	Other-follow up survey
Wheeler Clinic Kognito_CT SBI with Adolescents - Post_Survey 5-21-18.pdf	Other-Post survey
Wheeler Clinic Kognito_CT SBI with Adolescents - Pre _Survey 5-21-18.pdf	Other-Pre Survey
0990-0379 Wheeler Fast Track OMB Clearance Form - Kognito Training Surveys- 5-21-18.docx SS_mini	IC Document
Wheeler Clinic Adolescent SBI Kognito Registraion Instructions 5-23-18.docx Instructions	IC Document

IC Title:

Adolescent SBIRT (A-SBIRT) Online Training (Kognito) Feedback Surveys

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-follow up survey	Wheeler Clinic Kognito_CT SBI with Adolescents - Follow up_Survey 5-21-18.pdf	Yes	Yes	Fillable Fileable
Other-Post survey	Wheeler Clinic Kognito_CT SBI with Adolescents - Post_Survey 5-21-18.pdf	Yes	Yes	Fillable Fileable
Other-Pre Survey	Wheeler Clinic Kognito_CT SBI with Adolescents - Pre _Survey 5-21-18.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SS_mini	0990-0379 Wheeler Fast Track OMB Clearance Form - Kognito Training Surveys- 5-21-18.docx	05/22/2018
Instructions	Wheeler Clinic Adolescent SBI Kognito Registraion Instructions 5-23-18.docx	05/22/2018

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