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

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.