OMB
.report
Search
Adolescent SBIRT (A-SBIRT) Online Training (Kognito) Feedback Surveys
Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery
OMB: 0990-0379
IC ID: 229754
OMB.report
HHS/HHSDM
OMB 0990-0379
ICR 201708-0990-001
IC 229754
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0379 can be found here:
2024-07-08 - No material or nonsubstantive change to a currently approved collection
2024-02-28 - No material or nonsubstantive change to a currently approved collection
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
View Information Collection (IC)
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
Form No.
Form Name
Instrument File
URL
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
Federal Enterprise Architecture Business Reference Module
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 New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,000
0
1,000
0
0
0
Annual IC Time Burden (Hours)
400
0
400
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.