Information Collection

Adolescent SBIRT (A-SBIRT) In-Person Training Feedback Surveys: a) Satisfaction and Retrospective Knowledge and Awareness Survey b) A-SBIRT 3 month/6 month Usage Feedback Survey(s)

IC 229755 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
A-SBIRT In-PersonTraining Knowledge and Awareness Survey - 5-21-18.pdf Other-survey
Wheeler Clinic SurveyMonkey-InPreson Training_3 Month Survey 5-21-18.pdf Other-Survey
Wheeler Clinic SurveyMonkey-InPreson Training_6 Month Survey 5-21-18.pdf Other-survey
0990-0379 Wheeler Clinic FastTrackGeneric Clearance Submission_Adolescent SBIRT (A-SBIRT) In-Person Training Feedback Surveys 5-20-18 (002).docx Mini SS IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Adolescent SBIRT (A-SBIRT) In-Person Training Feedback Surveys: a) Satisfaction and Retrospective Knowledge and Awareness Survey b) A-SBIRT 3 month/6 month Usage Feedback Survey(s)	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-survey	A-SBIRT In-PersonTraining Knowledge and Awareness Survey - 5-21-18.pdf	Yes	Yes	Fillable Fileable
Other-Survey	Wheeler Clinic SurveyMonkey-InPreson Training_3 Month Survey 5-21-18.pdf	Yes	Yes	Fillable Fileable
Other-survey	Wheeler Clinic SurveyMonkey-InPreson Training_6 Month 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: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	175	175
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Mini SS	0990-0379 Wheeler Clinic FastTrackGeneric Clearance Submission_Adolescent SBIRT (A-SBIRT) In-Person Training Feedback Surveys 5-20-18 (002).docx	05/22/2018

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