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⚠️ Notice: This information collection may be referencing outdated material.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

2024-09-11 - No material or nonsubstantive change to a currently approved collection
2024-07-08 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
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:

table that charts list of 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

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: 500

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	500	500
Annual IC Time Burden (Hours)	175	175
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.